Musculoskeletal System/Rheumatologic Upper Extremities Bursitis Fractures – wrist ▪ Causes: injury or trauma; prolonged pressure; overuse or ▪ Colle’s Fracture (outward) – wrist gets bent backwards strenuous activity; crystal-induced arthropathy; and ▪ Smith’s Fracture (inward) – wrist gets bent forwards inflammatory arthritis ▪ Results from a fall onto the hand ▪ Swelling, pain ▪ Pain, deformity, MOI ▪ ↓ Active ROM, Full passive ROM o Colles – most common injury of the wrist – distal ▪ NSAIDs radius fracture w/ dorsal angulation ▪ ***The two main indications to aspirate a bursa are to rule out ▪ Dx  Xray infection, and to aid in the diagnosis of a microcrystalline ▪ Tx  Cast immobilization after reduction disorder like gout. ▪ *** Radius & ulna fractures comprise the largest proportion of fractures (44%) Tendinitis ▪ Most affected group 5-14 years (26%) ▪ NSAIDs & Rest (ice, compression, elevation) ▪ PT/OT or brace may be useful ▪ Achillis tendinitis is a common injury, particularly in sports that involve lunging and jumping ▪ Patellar tendinitis is a common among players with a lot of jumping and landing Strain/sprain – wrist Rotator cuff injuries ▪ Sprain – ligaments ▪ ***“SITS” muscles: Supraspinatus, Infraspinatus, Teres ▪ Strains – muscles, tendons minor, Subscapularis ▪ Acute – athletes, laborer, weekend worrier ▪ **Supraspinatus most commonly injured ▪ Chronic – overuse, repetitive use at work, sports ▪ Rare to have an isolated tear of other muscles ▪ Swelling, pain, tenderness, discoloration of skin, may hear a ▪ Usually tear from abduction and rotation “popping” or tearing inside wrist ▪ Acute shoulder pain, night pain ▪ Clinical dx  Xray or MRI to confirm ▪ 90% of acute injuries are exacerbations of a chronic RTC tear ▪ Tx ▪ Inability to abduct arm, externally rotate arm against o Protection  splint resistance o Rest ▪ Drop arm test is “+” o Ice  through splint ▪ Diffuse atrophy of shoulder musculature o Compression Ace wrap ▪ Dx  Xrays helpful to r/o tendonitis, tumors, arthrosis o Elevation  above heart o Arthrography or MRI may be used to dx tears ▪ *** If left untreated, can become a SLAC wrist (scapho-lunate ▪ Tx advanced collapse) o pain meds, ice, ortho referral, prevent frozen should or adhesive capsulitis if possible o Want to repair within 3-4 months ▪ Usually >40 y/o Impingement syndrome Adhesive capsulitis ▪ Anything that entraps RTC muscles under acromion ▪ Inflammatory process that may follow injury to the shoulder ▪ HPI: repetitive overhead work or fall on hand or arise on its own ▪ pain at greater tuberosity, lateral shoulder ▪ Characterized by pain and restricted gleno-humeral ▪ Pain and difficulty abducting arm movement ▪ Positive Neer impingement and Hawkins signs ▪ Often preceded by insignificant injury ▪ Dx  clinical (MRI to r/o RTC tear if not improving w/ tx) ▪ Decreased shoulder ROM, especially abduction and flexion ▪ Tx: rest, ice, NSAIDs, PT, steroid injections ▪ Passive ROM limited by firm resistance ▪ If not better after 6-12 wks, may consider surgery ▪ Dx o Arthrograthy may show decreased volume of the joint capsule and capsular contraction ▪ Tx o Aggressive home exercise program and PT o Passive ROM, NSAIDs o Operative manipulation when exercises fail o Not a permanent loss of motion! ▪ *** More common in women and diabetics o If they have this on top of an RTC tear, need tear to clear before address this

Lateral Epicondylitis (“tennis elbow”) De Quervain’s ▪ Overuse, repetitive supination and wrist extension ▪ A stenosing tenosynovitis – most common tendonitis in wrist ▪ Most common overuse injury of the elbow ▪ Age: 30 – 50, women & diabetics ▪ Point tenderness over lateral epicondyle o Lifting your child repeatedly involves using your ▪ Pain on resisted wrist extension thumbs as leverage ▪ Clinical diagnosis o Jobs or hobbies that involve repetitive hand and o x-ray to r/o arthritis, may show osteophytes overlying wrist motions lateral epicondyle ▪ Painful condition involving tendons on thumb side of wrist o MRI may be useful in demonstrating tendon ▪ difficulty moving thumb/wrist when grasping or pinching disruption ▪ Pain/tenderness/swelling near base of thumb ▪ Tx ▪ Radiation of pain up forearm is common o Rest (at least 6 wks), Ice, NSAIDs ▪ Dx o counter force strap (counterbalance brace) o Swelling and thickening of tendon sheath may be o Steroid injection, a few may require surgery appreciated ▪ ***Extensor muscles attach to the lateral epicondyle o Finkelstein test!

Medial Epicondylitis (“golfer’s elbow, baseball elbow”) ▪ Affects the flexor-pronator muscles ▪ Point tenderness over medial epicondyle ▪ Pain on resisted wrist flexion or pronation

▪ Clinical diagnosis (x-ray to r/o arthritis or loose body) o Imaging (xrays) generally NOT needed to diagnose ▪ Tx ▪ Tx o Rest, ice, NSAIDs o Brace/thumb splint o Steroid injection, stretching/strengthening o NSAIDs, PT/OT ▪ *** Flexor muscles attach to the medial epicondyle o Cortisone injection/surgery if needed Olecranon bursitis Carpal tunnel syndrome ▪ Caused by acute injury or repetitive trauma to olecranon ▪ Compression of the median nerve under the transverse bursa; less frequently from skin breaks w/ septic cause (S. carpal ligament aureus) ▪ Can be precipitated by premenstrual fluid retention, early RA, ▪ May be painful, may also look reddened and appear like acromegaly, trauma, pregnancy, repetitive flexion/extension cellulitis of wrist, alcohol abuse ▪ Dx  Clinical dx (imaging not usually indicated unless ▪ Diabetes or metabolic disorders that make nerves more suspicion of fracture) susceptible to compression are at higher risk (lupus, RA) ▪ Tx ▪ Sx  Pain, night pain, numbness/tingling (paresthesia) in o Sling/pain meds/ice hand & wrist (spare little finger) o Ace wrap (compression) ▪ Dx  o Drain if infectious (yellow joint fluid) o Durkan’s test: reproduction of symptoms with o Abx if infectious carpal tunnel compression ▪ *** ROM usually preserved o Phalen’s sign: reproduction of symptoms with wrist hyperflexion o Tinel’s sign: reproduction of symptoms with percussion over carpal tunnel o Flick sign: patient reports shaking of the hand provides relief ▪ Tx  NSAIDs, volar splint in neutral position o Surgical intervention may be needed to decompress nerve – 99% curative – most common and successful operative tx of peripheral nerves ▪ ***Most common mononeeuropathy Ganglion cyst Gamekeeper’s thumb (Thumb Sprain) ▪ Noncancerous mass, often on tendons or joints of wrist/hands ▪ Sprain or tear of the ulnar collateral ligament of thumb ▪ Round, small, fluid-filled masses, usually painless (unless ▪ Usually a hx of sprained thumb or fall on hand compressing nerve) ▪ Ligamentous laxity of the ulnar collateral ligament, with ▪ Clinical diagnosis instability and weakness of pinch ▪ Tx ▪ Clinical dx  MRI if unstable on exam o Observation & rest - often resolves on its own with ▪ Tx rest o Immobilization with splint o Immobilization o Surgical repair of UCL if complete rupture o Aspiration or surgery if it painful or disabling ▪ Stenner lesion – absolute indication for surgery ▪ *** Most common mass/lump of hand

Shoulder Dislocation Clavicle Fracture ▪ Usually anterior ▪ Usually a pediatric fracture ▪ Pt will support affected arm with the other arm ▪ MOI: direct force to lateral shoulder, fall or sporting injury ▪ May have loss of sensation over shoulder due to axillary nerve ▪ Affected extremity held close to body entrapment ▪ Shoulder is slumped downward, forward, and inward ▪ Management  Manual relocation, can resolve ▪ Management  Immobilization in figure 8 dressing spontaneously after a few weeks Scapula Fracture Humeral Shaft Fracture ▪ MOI: direct violent trauma ▪ Typically from trauma in the elderly ▪ May also have injury to ribs, chest wall, or shoulder girdle ▪ Extensive bruising of upper arm ▪ Shoulder is adducted and arm is held close to the body ▪ Wrist drop from radial nerve damage ▪ Immobilization with sling and swathe dressing ▪ Wrist splinting and casting over site of break Supracondylar Fracture Radial Head Fracture ▪ Pediatric fracture ▪ MOI: FOOSH ▪ Usually involves distal humerus ▪ Decreased ROM in elbow ▪ Limb ischemia if branchial artery is damaged ▪ Difficult to see on x-ray, may see displacement of fat pad, ▪ X-ray showing posterior sail sign, anterior humeral line drawn elbow effusion will not bisect the capitate ▪ Assess neurovascular involvement, check radial pulses! Colles Fracture of Distal Radius Scaphoid Fracture ▪ MOI: FOOSH  posterior displacement of wrist (“dinner fork ▪ FOOSH deformity”) ▪ Fullness or pain in the anatomical snuffbox ▪ Casting alone if nondisplaced ▪ Possibly negative x-ray (4 view x-ray - repeat imaging in 10-14 ▪ Closed reduction followed by casting if slightly displaced days if negative) ▪ ORIF & short arm cast if displaced ▪ Management  Immobilize in thumb spica ▪ ***Risk of AV necrosis due to poor blood supply Smith Fracture of Distal Radius Boxer’s Fracture of Distal 5th Metacarpal ▪ MOI: opposite Colles = fall on back of hand ▪ MOI: blow of closed fist against another object ▪ Splinting vs percutaneous pinning Lower Extremities Ankle Sprain • Patient with a history of ankle inversion • PE will show pain and swelling • Imaging will show partial or complete tearing of ligaments • Most commonly injured anterior talofibular ligament (ATFL) • Treatment is RICE therapy • Comments: Ottawa Rules to determine imaging

OTTAWA RULES: Do ANKLE xray if there is pain in the malleolar region with any of the following:

▪ Bone tenderness @ posterior edge of lateral malleolus ▪ Bone tenderness @ posterior edge of medial malleolus ▪ Inability to bear weight for at least 4 steps

Do FOOT series if there is pain in the mid-foot region with any of the following:

▪ Bone tenderness @ navicular bone ▪ Bone tenderness @ the base of the fifth metatarsal ▪ Inability to bear weight for at least 4 steps

ANKLE SPRAIN CLASSIFICATION: Grade 1  minimal tenderness & swelling (micro tears), treatment = weight bear as tolerated & PT Grade 2  moderate tenderness & swelling, decreased ROM, possible instability (complete tears or some), treatment = immobilize with air splint & PT Grade 3  significant tenderness & swelling, instability (complete rupture of ligament), treatment = immobilize, PT, possible surgical reconstruction

Meniscal injuries Slipped Capital Femoral Epiphysis ▪ Cartilage injury ▪ MOI: occurs when femoral head is displaced from the ▪ Medial & lateral menisci  most common knee injury femoral neck ▪ Occurs with excessive rotational force (twisting or slipping) ▪ Patient will be an obese male 12 - 16 years old ▪ Sx  Effusion (past or present) ▪ Complaining of a progressive limp and knee pain o -delayed swelling (overnight) ▪ PE will show loss of hip internal rotation o +/- locking or clicking (inability to fully extend) ▪ African American o “knee giving way”, difficulty w/ stairs ▪ Left hip > right hip ▪ Dx  + McMurray test & + Apley test (Clinical dx) ▪ Limp, hip or groin pain o Confirm with MRI prior to surgery o Affected leg turns out and appears shorter ▪ Tx  ▪ AP/lateral X-ray of bilateral hips o Rest, ice, elevation o Xray will show "scoop of ice cream slipping off an o NSAIDS ice cream cone" o Quad strengthening (PT) ▪ Abnormal Klein line ▪ *** Medial meniscus injured most often ▪ Non-weight bearing ▪ An orthopedic emergency, requires surgical repair Acute and chronic lower back pain Plantar fasciitis ▪ 80% of US population will have episode of back pain, caused ▪ Most common cause of heel pain by overuse, heavy lifting/twisting ▪ Caused by microscopic tears in plantar fascia ▪ Low back pain that may radiate to buttock or leg (sciatica) ▪ Often seen with recent increase of activity ▪ Worse with periods of long standing ▪ Pain with first steps in morning then improves ▪ Tenderness over paraspinal muscles, sciatic n. palpation, and ▪ Tender along plantar fascia decreased lumbar ROM ▪ Clinical dx ▪ Neuro exam will be normal ▪ Tx ▪ Dx: Clinical  Xray to r/o other causes if sx persist o Rest/decreased activity ▪ Tx o Stretch PF & calves o Rest, ice/heat, NSAIDs o NSAIDS, ice, massage o PT, education o Heel cushion, night splint injection, surg last resort o Narcotics + muscle relaxants for short time (~3d) ▪ *** Common in runners and overweight pts Pediatric Fractures Fractures Associated with Child Abuse ▪ Bowing and greenstick fx are unique to kids due to their ▪ Metaphyseal corner fx: child abuse until proven otherwise skeletal immaturity ▪ Posterior rib fx: child abuse until proven otherwise ▪ Growth plate fx are classified by Salter-Harris ▪ Any fracture in a child under 1 ▪ Most fx only require closed reduction ▪ LE fracture in a non-ambulatory child ▪ Kids heal faster due to more active periosteum and higher % ▪ Multiple fractures in various stages of healing cartilage ▪ Sternal or scapular fx: high impact mechanism such as MVC required or else it may be child abuse ▪ Spinous process fracture Hip Fractures Ankle Fracture ▪ Typically occurs in elderly females (mortality 20-35%) ▪ Involves lateral, medial, or posterior malleolus ▪ Extracapsular: ▪ MOI: eversion or lateral rotation on the talus o Does not affect blood supply to femoral head = ▪ Foot fracture (Involves talus, calcaneus, metatarsals, or complications of nonunion are rare phalanges) o Stable vs unstable (detached fragment of lesser ▪ Sx  Tenderness in these areas suggests fracture vs strain or trochanter) sprain (Ottawa ankle rules) o Tx with Internal fixation ▪ Workup  Ottawa ankle rules help determine need for x-ray ▪ Intracapsular: o Standard AP and lateral views on x-ray (plus AP view o Can affect blood supply to femoral head, especially if with 15° internal rotation if suspecting ankle displaced  nonunion and avascular necrosis fracture) o Internal fixation if no displacement ▪ Management & Prognosis  Elevation and ice, short leg cast o Hemiarthroplasty often the treatment of choice due to high risk of avascular necrosis Knee Fractures (patella/tibial plateau) Complications of fractures ▪ Sx  Knee pain, difficulty walking, swelling and bruising ▪ Most commonly DVT or PE o Aspiration will show hemarthrosis with fat globules ▪ Compartment syndrome o Point tenderness ▪ Avascular necrosis ▪ Management ▪ Nerve injury o Lower extremity immobilization and no weight ▪ Malunion, nonunion, or delayed union bearing ▪ Complex regional pain syndrome form injury to sympathetics (burning pain, skin changes, swelling, excessive sweating at site of injury) Other Osgood‐Schlatter Disease Henoch‐Schonlein Purpura (AKA immunoglobulin A vasculitis) ▪ Inflammation over insertion point of patellar tendon in tibial • Small vessel vasculitis in which complexes of IgA are tuberosity (avulsion due to overuse) deposited in the blood vessels ▪ -Most common in boys age 10-15 • Children 4-12 years old ▪ Signs & symptoms • Follows URI o Pain/tenderness & tibial tuberosity • Arthritis + purpura + GI sx o Anterior knee pain that increases gradually • May have heme positive stool, microscopic hematuria or o Worse with kneeling, jumping, squatting, or stairs proteinuria o Relieved by rest • Complications: nephropathy, intussusception ▪ Workup • Rx: supportive care (symptomatic relief, can be treated o X-ray to rule out fracture with steroids) ▪ Management o Self-resolving o Rest & NSAIDs Kawasaki Disease Osteoporosis ▪ medium-sized arteries ▪ Decline in bone mass with aging → ↑ bone fragility + ↑ ▪ Patient will be a child < 4 years old fracture risk (F > M) ▪ With a history of high fever for 5 days ▪ Risk factors: alcohol, steroid use, whites, Asians, cigarettes, ▪ Complaining of conjunctivitis, rash, adenopathy, strawberry meds (depo, anticoags, GnRH agonists), low body weight tongue, hand/feet edema, fever o Most common fracture: vertebral body ▪ Treatment is IVIG + aspirin compression fractures ▪ Comments: #1 cause of pediatric acquired heart disease, risk ▪ DEXA scan  Screen women of average risk >65 for coronary artery aneurysm ▪ Screen women younger if they have risk factors ▪ Mnemonic: o If osteopenia (1.0-2.5), screen again 1-5 yrs later CRASH and burn: Conjunctivitis, Rash, Adenopathy, Strawberry o T-score ≤ -2.5 tongue, Hand/feet edema, Fever ▪ Prevention: weight-bearing exercises, calcium, vitamin D, ▪ Cardiac Manifestations: smoking cessation Pharmacologic rx: bisphosphonates o 25% of untreated patients go on to develop coronary ▪ Bisphosphonates  MOA: inhibit bone resorption artery aneurysm o Alendronate, resideronate, ibandronate ▪ Treatment o Must take on empty stomach and sitting upright o IVIG – IV infusion of gamma globulin  lowers risk of o AEs: hypocalcemia, dysphagia, esophageal coronary artery complications inflammation, gastric ulcer, visual disturbance, o Aspirin - High doses of aspirin may help treat arthralgia, HA, myalgia, fever after first dose inflammation. Aspirin can also decrease pain and o Possible atypical femoral fx = take break every 5 joint inflammation, as well as reduce the fever. years ▪ High dose in acute stage o Possible osteonecrosis of the jaw in cancer pts ▪ Low dose for months until labs normalize receiving IV treatment ▪ Prognosis  Kawasaki disease is usually treatable, and most o Contraindications: inability to sit upright for 30 min, children recover from Kawasaki disease without serious esophageal strictures, hypocalcemia problems. ▪ VitD = 800-1000 IU daily ▪ Calcium = 500-600 mg BID Costochondritis Overuse syndrome • An acute and temporary inflammation of the costal cartilage • Tendon thickening and chronic, localized tendon pain • Common cause of chest pain • Not typically associated with inflammation • Often resolves on its own • Risk factors • Etiology o Advancing age and increased overall volume or o Most cases = unknown intensity of tendon load pose the greatest risk for o Physical trauma, scoliosis, RA, OA developing overuse tendinopathy o Viral: Costochondritis commonly occurs with viral • The major clinical features associated with tendinopathy are respiratory infections because of the inflammation of pain with palpation of the affected part of the tendon and the area from the viral infection itself, or from pain with tendon loading straining from coughing o Bacterial: Costochondritis may occur after surgery and be caused by bacterial infections. o Fungal – rare • Sx  Tenderness to palpation, affects multiple ribs, worsened with coughing, deep breating, or physical activity • Tx  NSAIDs, opiates if needed, can do corticosteroids to unresponsive cases

Rheumatologic Disorders Gout • Patient will be a middle-aged man • Complaining of acute onset of pain in the first MTP (Podagra) • Labs will show needle-shaped crystal with negative birefringence • Most commonly caused by uric acid crystals • Treatment is: • Acute: NSAIDs (indomethacin) • Chronic: allopurinol or colchicine • Comments: can be triggered by loop and thiazide diuretics

Pseudogout • M=F, >50 years old • Slower onset than gout • Positively birefringent, rhomboid- shaped, calcium pyrophosphate crystals • Knee • Rx: NSAIDs Rheumatoid Arthritis Polymyositis ▪ Women in 20s/30s ▪ Inflammatory muscle disease  proximal weakness of the ▪ Autoimmune destruction of synovial joints skeletal muscles ▪ Morning stiffness lasting > 30 minutes ▪ Caused by killer T-cells attacking muscle cells expressing ▪ Fatigue MHC class I (slow fibers) ▪ MCP, PIP ▪ May be triggered by certain cancers ▪ Bilateral ulnar deviation at MCP ▪ Baker's cyst, swan neck deformity, boutonniere deformity ▪ Sx  Insidious onset, proximal muscle weakness (can’t get ▪ Symmetrical, bone errosions on xray & joint space narrowing up from chair), muscle atrophy, low-grade fever, peripheral ▪ Systemic sx lymphadenopathy o Lung: interstitial fibrosis, effusions ▪ Workup  LDH, LFTs, ANA, EMG, muscle bx o Spine: atlantoaxial joint subluxation; ▪ Management  High dose steroid taper cord/vertebral artery compression o DMARDS for patients unresponsive to steroids o Anemia ▪ Labs  RF, ESR, CRP ▪ NSAIDs, glucocorticoids, DMARDS (MTX), TNF inhibitor Consider polymyalgia rheumatica if (+) ESR & CRP (though not required) and (-) RF

Fibromyalgia Antiphospholipid Antibody Syndrome • Patient will be a woman • Patient with a history of lupus or other rheumatic • Complaining of widespread musculoskeletal pain for > 3 diseases months, non-restorative sleep and generalized fatigue • Complaining of repeated spontaneous abortions • PE will show tenderness at > 9 of 18 anatomic sites (“trigger • Labs will show thrombocytopenia points”) • Most commonly caused by autoimmune • Labs will be normal • Treatment is anti-coagulation • Diagnosis is made clinically • Treatment is education, antidepressants, avoid opioids

Systemic lupus erythematosus • African-Americans, females • Malar rash • Arthritis • Renal disease • Cardiac: fibrinous pericarditis, Libman-Sacks endocarditis • CNS: HA, stroke, seizures • Drug induced: Hydralazine, INH, Procainamide, Phenytoin, Sulfonamides (HIPPS) • Antinuclear antibodies (ANA): 100% sensitive, not specific • Anti-dsDNA antibodies: 100% specific, poor prognosis • Anti-Smith antibodies: 100% specific, not prognostic • Antihistone antibodies: sensitive for drug-induced lupus • NSAIDs, steroids, immunosuppressants, hydroxychloroquine

Scleroderma Polymyalgia rheumatic ▪ Excessive collagen deposition • More common in women > 50 years old ▪ F > M • Pain, stiffness in shoulders and hips (~1 month) ▪ Raynaud's phenomenon • Fever, malaise, weight loss common ▪ GI: dysmotility, dysphagia • No weakness ▪ Pulmonary: pulmonary • Lab findings: ↑ ESR, ↑ CRP, normal CK hypertension, interstitial fibrosis • Temporal (giant cell) arteritis ▪ Renal: malignant HTN,

arteriosclerosis • Rx: steroids (prednisone) ▪ CREST: Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasia ▪ Systemic: anti-SCL-70 antibody, ANA ▪ anticentromere antibody, ANA Sjogren’s Syndrome: Reactive Arthritis (Reiter’s) • Characterized by dry eyes (keratoconjunctiva sicca), and dry • Patient with a history of recent GI or Chlamydia infection mouth (xerostomia) • Complaining of acute asymmetric arthritis • Destruction of lacrimal and salivary glands • PE will show conjunctivitis, arthritis, urethritis • Can be associated with RA or on its own • Labs will show HLA-B27 • Why It’s Important: • Treatment is NSAIDs o 9x more common in women • Comments: “Can’t see” (uveitis), “can’t pee” (urethritis), o INCREASED RISK FOR B-CELL LYMPHOMA (44x) “can’t climb a tree” (arthritis) • Diagnosis: • ***Can be associated with immune response to enteric or o Need ocular symptoms, oral sx GU organisms (shigella, salmonella, Yersinia, chlamydia) o Autoantibodies (Ro-SSA or La-SSB, ANA, or RF) o Parotid enlargement (usually bilateral) • Clinical Presentation: o Dry eyes, mouth, skin, vagina o Salivary gland enlargement (30-60%, usually bilateral) o Skin: vasculitis purpura, raynaud’s Osteoarthritis Osteosarcoma ▪ Progressive destruction of articular cartilage by proteolytic ▪ Osteosarcoma is the most common primary malignancy of enzymes, remodeling of subchondral bone the bone ▪ Stiffness worse w/ activity, relieved with rest ▪ Bimodal age distribution with peaks in early adolescence ▪ Hard, bony swollen joints and in adults over the age of 65. ▪ Typical finger joints: DIPs, CMCs of thumbs o 10–20 years old, > 65 years old ▪ Heberden (DIP) & Bouchard (PIP) nodes ▪ Sx  pain and swelling ▪ Osteophytes ▪ Dx  X-ray: Codman's triangle, sunburst pattern ▪ Limited movement, crepitus, joint effusion ▪ Can be caused by ionizing radiation for treatment of ▪ Thinned cartilage, bone ends rub together childhood solid cancers (example retinoblastoma) ▪ Labs: typically normal ESR & RF ▪ More common in the long bones with the most frequent ▪ Clear viscous synovial fluid w/ WBC <2k sites in descending order being femur, tibia, and humerus ▪ Tx: ▪ Most common malignant bone tumor o Weight loss, PT, joint protection, physiotherapy (heat, cold), orthotics o NSAIDs, Tramadol, Intraarticular corticosteroids o Arthroscopic irrigation or synovectomy, arthroplasty, o Artificial joints Septic arthritis Acute/Chronic Osteomyelitis • Age <35: N. gonorrhea • S. aureus most common overall • Hematogenous spread • Fever, pain, ↓ ROM • Knee (most common) • Arthrocentesis (WBC >50,000 with >75% PMNs) • IV ABX, surgical washout

Ankylosing Spondylitis Avascular Necrosis • HLA-B27 • Causes: corticosteroids (most common), alcohol • Sacroiliac joints and spine • Most common site: femoral head • Low back pain: worse in the morning, improves with exercise • MRI • X-ray: bamboo spine • ↑ ESR • Uveitis, aortic regurgitation • NSAIDs, MTX, physical therapy, spinal fusion Peripheral Neuropathies Pelvic Avulsion Fracture • Sciatic: buttock injury, hip dislocation, ↓ knee flexion, • Powerful contraction of lower leg muscle on a foot drop, rx: ankle splint developing apophysis • Common peroneal: proximal fibula injury, footdrop, rx: • Most common type ischial tuberosity avulsion ankle splint • Diagnosed with AP and frog leg radiographs • Radial: crutches, wrist/finger drop, rx: wrist splint • Treated with rest, crutch use and pain control • Ulnar: elbow injury, ↓ finger adduction/thumb • Surgical pinning rarely required grasp, 4th/5th digit paresthesias • Lateral femoral cutaneous: inguinal ligament entrapment, upper thigh dysesthesia/numbness

Multiple Myeloma Osteogenesis Imperfecta (“Brittle Bone” Disease) • Single clone plasma call malignancy • Patient with a family history of similar symptoms • Elderly • Complaining of hearing loss, easy bruisability, or multiple • CRAB: hyperCalcemia, Renal insufficiency, Anemia, fractures lytic Bone lesions/Back pain • PE will show blue sclera, increased laxity of joints and skin, • X-ray: lytic lesions short stature, scoliosis, basilar skull deformities • Monoclonal antibody spike • Most commonly caused by autosomal dominant mutation in • PBS: Rouleaux formations collagen • SPEP: M spike • UPEP: Bence-Jo

Polyarteritis nodosa Lisfranc Injury • Proximal myalgia and weakness • Definition: any fracture or dislocation of the tarsal-metatarsal • Skin ulcers joint • Nephritis • Plantar ecchymosis • Mesenteric ischemia • Fleck sign (pathognomonic): avulsion fracture of the medial • Spares pulmonary vasculature aspect of the base of the second metatarsal • Hepatitis B seropositivity • Weight-bearing films may be necessary • DX: biopsy, mesenteric angiogram • Treatment: • HBV testing • Nondisplaced: non-weight bearing casting • Rx: steroids, cyclophosphamide • Displaced: surgery

Fractures @ growth -Salter Harris fractures plate Genusvarum -Bow-legged -Normal until 2yrs Genuvalgum -Knock knees -Normal until 8yrs Osgood Schlatter’s -Stresses on tibial tuberosity causes microevulsion Disease -Benign, resolves once child stops growing, resting from sports can provide comfort from pain but will not speed up resolution Clavicular Fractures -Common in newborns – breech, macrosomic, Vit D deficiency -Can be detected w/asymmetric Moro reflex Development Hip -Barlow and Ortolani screening tests, f/u US (can’t do XR  no ossification until 4-6mo) Dysplasia -US recommended all females born breech, all females w/FHx, questionable exam -“Lollypop on a stick” -Pavlic harness: for babies up to 6mo; harness leaves baby in position that allows hip to grow into correct placement -Short leg spica cast: cast that keeps baby in abducted position -If older than 18mo pelvic Dega osteotomy (open reduction  cut into hip bone and make place for femur) Legg-Calve-Perthes -Avascular necrosis of head of femur Disease -Best seen on MRI -Cannot internally rotate -More common in younger children Slipped Capital -Kline’s line should go through head of femur to hip Femoral Epiphysis -“Head of ice cream falls of the cone” (SCFE) -Surgical reduction to put pin through and hold in place -Has significantly higher lifetime risk than LCP (during teenage years with growth spurts) -Considered Salter Harris fracture Limping -Trauma -factures, stress fractures, toddlers fractures, soft tissue contusion, strain/sprain -Infection – osteomyelitis, Lyme dz, cellulitis, gonorrhea, post-infectious reactive arthritis, septic joint -Malignancy – bone spinal cord tumors, lymphoma, leukemia -Inflammation – JIA, transient synovitis, SLE -Congenital – DDH, sickle cell, club foot -Developmental – osteochondritis, LCP, SCFE Limping: All ages Septic arthritis, osteomyelitis, cellulitis, stress fracture, neoplasm, NSM Limping: Toddlers (1- Septic hip, DDH, occult fractures (child abuse), leg-length discrepancy 3yo) Limping: Child LCP, SCFE, transient synovitis, JIA (4-10yo) Limping: Adolescent SCFE, LCP, gonococcal arthritis (3% disseminated in untx), overuse injuries (11-16yo) Metatarsus -Adducted forefoot Adductus -Midfoot and hind foot normal (differentiates from club foot) Idiopathic Talipes -Aka “club foot” Equinovarus -Hypoplastic tarsals and foot bones, atrophy of calf muscle -Varus (goes inward) -Serial casting tx -25% risk if parent or sibling -More common in M, bilateral 50% Nursemaid’s Elbow -Annular ligament – rubber band that goes over head of radium -Gets pulled up and gets stuck, radial head gets sublaxed (trapped) -Supinate and flex to fix Greenstick Fracture -Bone angulated -Fall on tension side, bend deformity on compression side Buckle Fracture -Fall on an outstretched hand (torus) -Occurs in metaphysis Bucket Handle -Fragmentation by distal end of the bone only accomplished by shear forces Fracture -Suggestive of child abuse  call child services Other fractures -Bones that are hard to break  sternum, scapula, 2nd rib, spine suggestive of child -Posterior ribs abuse -Different stages of healing -Certain skull fractures  multiple “eggshell” fractures, occipital impression fractures, fractures crossing sutures -Diaphyseal fractures and spiral fractures -If fracture does not match mechanism of injury Supracondylar -Very common in kids Fracture -Elbow hyperextends -Fall on an outstretched hand -Surgical emergency  neurovascular compromise (brachial artery, median nerve), risk for compartment syndrome (Bulkman’s contracture) -Posterior fat pad abnormal, large anterior fat pad Spondylosis -Defect in pars interarticularis -Most commonly 5th lumbar vertebra -Lower back pain  numbness, tingling, stiffness Spondylolysis -Worsening of spondylosis Spondylolisthesis -Slippage and herniated disc

MUSCULOSKELETAL EMERGENCIES

Crush Injuries -Really a result of acute traumatic ischemia Signs & Symptoms Workup Management -Rhabdomyolysis from sarcolemma failure  -Fractures -Electrolytes: hyperkalemia, -Can give bicarb before extrication to shift K+ intracellularly permeability of muscle membranes  leak of myoglobin -Evident soft tissue injury hyperphosphatemia, hypocalcemia -Can give Ca carbonate for K+ cardiac membrane stabilization and K+ out of cell with leak in of water, Ca, Na -Dysrhythmias and EKG changes -High myoglobin post-extrication (different IV from bicarb!) -Also have local vasoconstriction and platelet (peaked T waves, loss of P waves) from -Elevated CK -Give insulin with D50W to shift K+ intracellularly aggregation  ischemia electrolyte imbalances (officially rhabdo if > 5x ULN) -Albuterol to raise insulin level  more intracellular K+ shift -Compartment syndrome from increased pressure within -Red-brown urine -Elevated Cr due to AKI from trying -Kayexalate to reduce K+ via GI tract (slower onset of action) muscle compartments  muscle, tissue, and nerve to clear myoglobin -Remove any constrictive clothing, jewelry, or splints death Compartment syndrome: tight, shiny, -Avoid large boluses of fluid if pt is hemodynamically stable pain out of proportion to exam, Management -Mannitol: a non-osmotic diuretic to help wash myoglobin out  pain, pressure or -ABCs of renal tubules to protect kidneys poikilothermia, paralysis, -Cardiac monitoring -Compartment syndrome: fasciotomy, hyperbaric oxygen paresthesia, pallor, -Fluid resuscitation pulselessness -Pain management Prognosis  >30mmHg indicates need for -Degree of physiologic dysfunction is not related to time surgical decompression elapsed before extrication

Fractures Pediatric Fractures ▪ I: S (Slipped epiphysis) General Information -Greenstick fx = one side broken, other bent ▪ II: A (fracture Above physis), most Presentation -Buckle / Torus fx = compression fx common -Will always cause pain -Growth plate fx are classified by Salter-Harris ▪ III: L (fracture beLow physis) -Tender, swollen, and with mobility at the fracture site -Most fx only require closed reduction ▪ IV: T (fracture Through physis) -Loss of limb function -Kids heal faster due to more active periosteum and ▪ V: R (wRecked physis) ▪ I/II rx: nonoperative higher % cartilage Workup ▪ IV/V rx: surgery required -All suspected fx need at least 2 views for radiographs: AP, lateral ▪ Negative radiographs do not r/o a Salter I Fractures Associated with Child Abuse fracture -CT for subtle stress fractures or for inability to detect on x-ray but -Any fracture in a child under 1 with high suspicion -LE fracture in a non-ambulatory child -MRI: T1 for new fractures, T2 for older fractures -Multiple fractures in various stages of healing -isolated diaphyseal fx Complications

-rib & skulls fractures -Most commonly DVT or PE -Metaphyseal corner fx: child abuse -Compartment syndrome -multiple or bilateral fractures -Avascular necrosis -Sternal or scapular fx: high impact mechanism such as -Nerve injury MVC required or else it may be child abuse -Malunion, nonunion, or delayed union -Spinous process fracture -Complex regional pain syndrome form injury to sympathetics -burning pain, skin changes, -Lower specificity: clavicular fx, long bone fx swelling, excessive sweating at injury site *osteogenesis imperfecta may be confused w/ abuse

Upper Limb Fractures and Dislocations Shoulder Dislocation -95% anterior, 5% posterior -Pt will support affected arm with other arm standard xray views: Can resolve spontaneously -anterior d/t external rotations or excessive -Shoulder may appear flattened AP, transscapular, axillary abduction or extension -Prominent acromion view Tx: closed reduction w/ traction -posterior d/t seizures, electric shocks, -Displaced greater tuberosity and unusual subclavicular bulge + scapular manipulation direct blow to anterior shoulder -nerve injuries uncommon with anterior dislocations but most  traction-countertraction common nerve injured is axillar n.  see sensory loss over stimson technique lateral aspect of shoulder & weakened abduction -must document nerve exam d/t axillary nerve injuries May use conscious sedation or intra-articular block AC Separation MOI: fall on outstretched hand, fall on affected shoulder with the arm adducted S/sx: swelling with tenderness over AC joint, gross deformity w/ higher degree injury, pain with upper extremity movement Standard xray view: AP view of both clavicles Sprain = Sling, Torn = Surgery Scapula Fracture MOI: direct violent trauma (MVA) Consider lung injuries, rib fx, Immobilization with sling and Shoulder is adducted and arm is held close to the body shoulder injuries, chest wall swathe dressing Common areas of scapula fractured = glenoid, body, neck injuries Humeral Shaft MOI: proximal humeral fx is a common fx in -Extensive bruising of upper arm Complications: *adhesive Wrist splinting and casting over the elderly population -Wrist drop from radial nerve damage capsulitis, axillary n. injury, site of break AVN of humeral head Clavicle Fracture Usually a pediatric fracture Affected extremity held close to body Immobilization in figure 8 MOI: direct force to lateral shoulder from a Shoulder is slumped downward, forward, and inward dressing fall or sporting injury Supracondylar -Pediatric fracture AP & lateral xray of elbow Complications: Fracture -Usually involves distal humerus posterior fat pad sign (aka sail sign) is highly suggestive of occult fracture -AIN neuropraxia -MOI: fall on outstretched hand displacement of anterior humeral line (does not bisect the capitate) -radial nerve palsy  extension fx*: distal humeral fx is alteration of Baumann angle -ulnar nerve palsy (flexion-type) displaced posteriorly  flexion fx: displaced anteriorly Non-op management = long arm posterior splint Assess neurovascular involvement, check radial pulses! Operative = open vs. closed reduction with percutaneous pinning Lateral Condylar -MOI: FOOSH with extended elbow, traction forces, or acute varus stress Fracture Lateral epicondyle of distal humerus articulates w/ capitellum Nondisplaced or minimally displaced fx  immobilize with Medial Epicondyle -MOI: fall on outstretched arm, elbow dislocations, traumatic avulsion (overthrow), acute valgus sress during FOOSH, posterior stress, chronic sling or cast in 90d flexion Fracture muscular traction (throwing), Displaced fx  ORIF -Associated with elbow dislocation or subluxation -Medial epicondyle of distal humerus articulates w/ trochlea

Hand / Wrist / Finger Injuries Boxer’s Fracture Metacarpal neck fx of the 5th +/- 4th digit Management: Splinting vs percutaneous pinning

MOI: punch with a clenched fist Most are unstable

Operative intervention if: any rotational deformity, significant angulation, neurovascular compromise Mallet Finger Disruption or laceration or the extensor Management: tendon at the DIP Xray to distinguish soft vs. bony fracture If no associated fx, can splint DIP in extension MOI: blow against tip of extended finger If fx, may either splint or pin the fragment with sudden forced flexion Complication if untreated: swan neck deformity

Colles Fracture Transverse fx of metaphysis of distal radius, with dorsal displacement of distal portion -Coaptation splint -Casting alone if nondisplaced MOI: fall on an outstretched hand (wrist gets bent backwards) -Closed reduction followed by casting if slightly displaced -Displaced: ORIF & short arm cast Median nerve associated with colles fx Smith Fracture Transverse fx of metaphysis of distal radius, with volar displacement of distal fragment -ORIF & short arm cast

MOI: fall on back of hand (wrist gets bent inward) Scaphoid Fracture Most commonly injured carpal bone Xray: lateral & AP view +/- scaphoid view Repeat imaging in 10-14 days if negative, normal radiograph does not r/o scaphoid fx, may require f/u MRI MOI: fall on outstretched hand Immobilize in thumb spica S/Sx: Displaced fx often require ORIF Fullness or pain in the anatomical snuffbox Referred pain to anatomic snuff box w/ Risk of scaphoid AVN, non-union, malunion compression of thumb Galeazzi Fx Distal radial shaft fx with an associated distal radioulnar Monteggia Fx Fracture proximal 1/3 of ulna + dislocation of radial head joint dislocation

Tx: ORIF

Radial Head Fracture -MOI: FOOSH -Decreased ROM in elbow -Difficult to see on x-ray, may see displacement of fat pad, elbow effusion

Ankle and Foot Fractures Ankle Fracture Malleolar fx  lateral, medial, posterior Ottawa ankle rules help determine need for x-ray Standard AP and lateral views on x-ray (plus AP view with 15° internal rotation if MOI: caused by eversion, inversion, or lateral rotation; inability to bear weight suspecting ankle fracture) Pain, swelling, ecchymosis, instability Pain will be over bone vs. ligament -Deltoid ligament determines surgery or not Check proximal fibula for tenderness (they may have broken this as well), Check peroneal -Isolated lateral malleolus fracture  casting vs. boot for 6 weeks nerve (foot drop) -Bimalleolar  goes to surgery, ORIF because of instability (more ankle instability) Tenderness in these areas suggests fracture vs strain or sprain (Ottawa ankle rules) -Bimalleolar equivalent  fx of fibula / lateral malleolus ----Deltoid ligament involved  ends up in surgery because instability - ORIF vs. cast depending on stability

Foot Fracture Involves talus, calcaneus, metatarsals, phalanges pain, ecchymosis, edema over affected bone Jones fx = 5th metatarsal transverse fx at proximal aspect xray  AP, lateral, oblique MOI: load applied to the ball of the foot laterally non-displaced = protected vs. non weight-bearing Lisfranc fx = midfoot injury = metatarsal bones displaced for tarsus displaced = ORIF MOI: compression, rotation, axial load great toe fx = ORIF Lisfranc = may require ORIF Leg & Knee Injuries Patellar MOI: direct blow to patella -Knee pain, difficulty walking Lower extremity immobilization and no Fracture & Often a transverse fx -Swelling and bruising weight bearing Dislocation -Point tenderness -Nondisplaced – immobilization in full Lateral patellar dislocation most common -Pain on extension of knee extension *knee dislocations are considered orthopedic emergencies  consider arteriogram & -Aspiration will show -Wide displacement – often requires immediate relocation by longitudinal tracton hemarthrosis with fat globules surgical intervention

Pelvic & Hip Injuries Pelvic fractures Hip dislocations Major nerve roots in pelvis: lumbar & sacral Posterior dislocation: leg often shortened, adducted, internally rotated Structures that may be damaged with injury to lower pelvis: associated with sciatic nerve injury -nerve roots, bladder/urethra*, colon, rectum, anus Anterior dislocation: limb is adducted, externally rotation, extended Leading causes of pelvic fx = MVA, falls, crush injuries associated with femoral nerve injury Primary concern = AVN

Extracapsular -Does not affect blood supply to femoral head = -H/o fall or trauma -Internal fixation complications of nonunion are rare -Leg may be shortened and externally rotated if displacement is -Stable vs unstable (detached fragment of lesser trochanter) present Intracapsular -Can affect blood supply to femoral head, especially if displaced = -May also have fx at another site, usually proximal humerus or distal -Internal fixation if no displacement commonly complications with nonunion and avascular necrosis radius -Hemiarthroplasty often the treatment of -Rarely neurovascular injury, but can have sciatic nerve injury choice due to high risk of avascular necrosis

Toddler -Spiral fx of distal tibia, Typically in 1-3 year olds, Salter-Harris -X-ray: may show subtle fracture only on -Long-leg casting Fracture Tibia classification 1 view

Neck & Spine Injuries Spinal Cord Injuries 3 main spinal cord pathways: Dorsal column  position & vibration Spinothalamic pathway  pain & temperature Corticospinal pathway  movement

Complete SCI = irreparable damage w / no discernible motor, sensory, or electrical function

Incomplete SCI = some preservation of sensory and/or motor Posterior cord injury  loss of position & vibration Anterior cord injury  loss of bilateral motor, temp, pain Central cord injury  loss of pain, temp, & motor (arms>legs) Cauda Equina Cauda equina syndrome is defined by a constellation of symptoms that result from Bilateral leg pain Syndrome terminal spinal nerve root compression in the lumbosacral region Saddle anesthesia Etiologies: disc herniation*, spinal stenosis, trauma, tumors, spinal epidural Bowel & bladder dysfunction (retention  overvlow incontinence) hematoma, epidural abscess Lower extremity sensory motor changes *true emergency  emergent MRI *can be associated with DVTs Tx = urgent surigical decompression within 48hrs (discectomy, laminectomy)

Spondylolysis -Stress fx of pars interarticularis, usually L5 X-ray showing scotty dog -Modification of activities -Seen in gymnasts, football players, weight lifters with collar -Core strengthening -Pain adjacent to midline, aggravated with extension & rotation -May be asymptomatic

Disc Herniation S/sx: Back pain, radicular pain, cauda equine

Dx: typically no need to image, but MRI if red flags: infection (IV drug user, h/o of fever and chills) tumor (h/o or cancer) trauma (h/o car accident or fall) cauda equina syndrome (bowel/bladder changes)

Tx usually conservative and non-operative (usually resolves in 4-6wks) Rest, PT, NSAIDs, muscle relaxants, oral steroid taper, steroid injections Laminectoy, discectomy

Low Back Pain Differential Red Flags for Serious Etiology Workup -Muscle strain -Trauma -Judicious use of irradiation, especially in younger patients -Osteoarthritis -Unexplained weight loss -Imaging indicated in first 4-6 weeks of symptoms only for: -Herniated disc -Age > 50 or h/o osteoporosis or • progressive neuro sx -Spinal stenosis prolonged corticosteroids • constitutional sx -Sciatica -Unexplained fever • h/o traumatic onset -Sacroillitis -History of urinary or other infx • h/o malignancy -Rheumatoid arthritis -Immunosuppression or DM • age > 50 years -Metastatic cancer -H/o cancer • infectious risk -Compression fracture -IV drug use • osteoporosis -Osteomyelitis -Age > 70 -If symptoms > 4-6 weeks, then plain AP and lateral views of lumbosacral spine are indicated -Epidural abscess -Focal neuro deficits or -CT or MRI (preferred modality) indicated for progressive neuro deficits or high suspicion of cancer or malignancy and only for those with > 12 -Cauda equina tumor progressive or disabling weeks of symptoms -Ischial bursitis symptoms -Piriformis syndrome -Duration > 6 weeks Management -Fibromyalgia -Prior surgery -Up to 90% of patients with back pain that don’t have systemic symptoms or sciatic will improve rapidly without any intervention -Aortic aneurysm -Nighttime pain -Acute low back pain: minimal activity modification with return to usual activities ASAP, short term NSAIDs ± muscle relaxants -Duodenal ulcer -Bladder dysfunction -Chronic pain: opioids only for acute exacerbations, no muscle relaxants, PT referral, acupuncture -Kidney stones -Saddle pattern anesthesia -Neurosurg or ortho consult for cauda equina, suspected cord compression, or progressive/severe neuro deficit -Pyelonephritis -Neuro or PT consult for neuromo -Pancreatitis Physical Exam tor deficits persisting after 4-6 weeks of conservative therapy, persistent sciatica/sensory deficit -Prostatitis -Inspect gait and spinal motion -Hip osteoarthritis -Spinal palpation -Straight leg raise test • Night pain, weight loss: malignancy -Peripheral pulses • -Focused neuro exam Back pain + fever + neurological deficits: epidural abscess -Testing of L5 and S1 nerve • Acute bony tenderness: fracture roots via reflexes and sensation • Young, morning stiffness: seronegative spondyloarthropathy • Urinary retention: cauda equina syndrome • Pain with extension, relief with flexion: spinal stenosis • Image if red flags present

Soft Tissue Injuries & Infections Osteomyelitis Infection of bone characterized by progressive inflammatory destruction and apposition of new bone Pain, erythema, edema, tenderness, fever risk factors: recent trauma, surgery, immunocompromised, IV drug use, poor vascular supply, systemic conditions (DM), peripheral neuropathy S. aureus is most common agent in adults Work up: WBC, ESR, CRP, blood cx, sinus tract cx, bone biopsy* (gold standard for anti-biotic coverage) Xray (bone loss must be ~35% to be evident): often shows a lytic region surrounded by an area of sclerosis Tx: IV or oral abx for 4-6wks, may need surgical irrigation & debridement

Septic Joint Usually acute presentation with single swollen and painful joint Pain, swelling, warmth, restricted movement S. aureus (>50%) is most common, N. gonorrhea (20%), gram negative bacilli (10% - elderly, neonates, immunocompromised pts, IVDU) Etiologies of bacterial seeding; bacteremia, direct inoculation (surgery, trauma), contiguous spread (from adjacent osteomyelitis) DDx: gout, pseudogout, cellulitis, bursitis Imaging studies likey show joint effusion Dx: CRP >5, ESR >30, WBC >10k w/ left shift, joint fluid aspiration = gold standard, saline fluid load test Tx: IV abx, operative irrigation and drainage of joint Avascular Necrosis Disruption of blood supply  leads to death of cells in bony matrix Pain, decreased ROM, crepitus, weakness MRI is preferred imaging modality Tx: pain meds, activity modification, PT, core decompression, arthoplasty Volkmann’s Ischemia Compartment syndrome of the upper extremity leading to deformity and contractures Fat Emboli Syndrome Symptoms usually occur 1–3 days after a traumatic injury  high index of suspic predominantly pulmonary (shortness of breath, hypoxemia), neurological (agitation, delirium, or coma), dermatological (petechial rash), and haematological (anaemia, low platelets) Strain stretching or microscopic tearing of a muscle and/or tendon Sprain injury to ligament when joint is carried thru a range of motion greater than (tendon = muscle to bone, ligament = bone to bone) normal Typically found in the knee, ankle, hand (example: ACL) Severity Severity Grade I (mild) = muscle stretched and painful but not torn Grade I (mild) – ligament stretched but not torn --no hematoma Grade II (moderate) – partial tear of ligament Grade II (moderate) = muscle intact w/ some tearing and bruising Grade III (severe) – complete tear of ligament --hematoma, typically treat non-operatively Grade III (severe) = complete tear including fascia, rupture is palpable --Requires repair (ex: quads rupture off patella) Rotator Cuff Shoulder pain, weakness, difficult w/ overhead activity Tendonitis/Bursitis /Tear Tendonopathy Pain with active abduction beyond 90 degrees (ie, painful arc sign) suggests rotator cuff tendinopathy. The test is most useful when combined with other rotator cuff tests, such as the Neer and Hawkins tests Neer & Hawkins tests – indicate impingement Tx: RICE, NSAIDs, PT Tear Likely tear if: active painful arc test, drop arm test, weak external rotation Weakness may help differentiate tendonitis vs. tear Xray, musculoskeletal ultrasound, MRI Bursitis joint protection, NSAIDs, glucocorticoid injections Biceps Action: supination and flexion of forearm Tendonitis/Rupture Speed’s test – elbow extended, arm supinated, forward flexion of shoulder against resistance Yeargeson’s test – patient flexes elbow 90d, pronates arm; pateint attemt to supinate against resistance of clinical holding hand Popeye deformity  A visible or palpable mass is often present near the elbow or in the mid-upper arm in cases of biceps tendon rupture Patella Tendon Bursitis: local tenderness over bursa, pain on motion & at rest, ocassional loss of active movement, swelling, erythema, warmth Bursitis/Tendonitis Tendonitis (jumper’s knee): infrapatellar pain, difficulty weight-bearing, popping sensation (suggests tendon rupture)

ACL & PCL Tears ACL PCL (Cruciate Ligaments) MOI: non-contact pivoting injury The “sag sign”, posterior drawer test Often associated with a meniscal tear S/Sx: pop, pain in knee, immediate swelling, hemarthrosis, effusion Lachman’s test  traction for anterior displacement of tibia Anterior Drawer test – bend knee and full anteriorly MCL & LCL Tears MCL LCL (Collateral Ligaments) Action: valgus stabilizer MOI: excessive varus stress, external tibial rotation, and/or hyperextension MOI: valgus and external rotation force to lateral knee S/Sx: lateral joint line pain & swelling, instability near full knee extension, difficulty S/sx: pop, medial joint line pain & tenderness, ecchymosis, effusion, difficuly moving ascending/descending stairs Tests: valgus stress test Tests: varus stress test MRI is modality of choice, can also order xray MRI is modality of choice Achilles Tendon MOI: traumatic injury, sudden forced plantar flexion, violent dorsiflexion in a plantarflexed foot Rupture S/sx: pop, weakness, difficulty walking, pain in heel, palpable gap Thompson test = lack of plantar flexion when calf is squeezed