When to Think About Fracture Major Trauma Minor Trauma/No Trauma (Pathological fractures) Bony tumor Osteoporosis Repetative/Unusual Activity Traumatic Fractures • Minor Trauma (sneeze, misstep, lift gallon of milk, raise window etc.) • Most common sites: vertebral bodies, femur and distal radius Age, race, body build Family history Disease states Risk Factors Long-­‐term exposure to Co-­‐morbidities 1 51 Medications/Toxins menopausal use) Diseases Hyperthyroidism Hyperparathyroidism Cushing’s Syndrome Hypogonadism Chronic Renal Failure Bony Metastasis Rheumatoid Arthritis Ankylosing Spondylitis IDDM Lymphoma Endometriosis Leukemia GI Malabsorption Syndrome Acromegaly Mul2ple Myeloma COPD Chronic Alcohol Dependency Stress Fractures • Insufficiency fractures: bone that is deficient in mineral content or elastic resistance. • Fatigue fractures: normal bone placed under overuse. 2 52 Fatigue Stress Fractures • Most common sites: –Tibia(20-­‐75%) Fatigue Stress Fxs: Risk Factors • Repetative overuse • Sudden change in training regimen • Alterations in training surface • Improper foot wear • Women • Leg length discrepancy • Diminished muscle strength • Pattern of decreased WB tolerance over time • Localized pain • Tenderness with palpation • Antalgic gait • MinimaljointROMlossforextra-­‐articular lesions • Special tests: tuning fork, patellar pubic percussion test etc. 3 53 4 54 5 55 6 56 Diagnostic Gold Standards • Sensitivities as low as 15-­‐29% Plain films can be (–) for 14-­‐21 days or longer!! • MRI and bone scan • edema • Grade2:T2image-­‐mod/severeperiosteal edema with marrow edema • Grade3:T2andT1images-­‐mod/severe periosteal edema with marrow edema • severe periosteal edema with marrow edema; plus obvious Fx line 7 57 8 58 2 1 Fatigue Stress Fxs: Complications • Risk for Fracture Progression Head/neck of femur (2-­‐9%) Groin, greater trochantor, deep buttock pain with WBing No palpable tenderness 9 59 Patellar Pubic Percussion Test • Normal bone has clear, “crisp” sound • Bony disruption results in a dull, muffled, diminished • LEs positioned symmetrically • “Grab” patella and hold Patellar Pubic Percussion Test The PPPT was only test that significantly altered post-­‐testprobability:Sensitivity0.95(95%CI review with meta-­‐analysis. Br J Sports med. Doi:10.1136/ bjsports-­‐2012-­‐091035 Interrater agreement of 90.2% (p<0.0001) Positive test warrants consideration of bone scan or MRI 60 Other Percussion Tests • Normal bone has clear, “crisp” sound • Bony disruption results in a dull, muffled, diminished • percuss olecranon) • Tibia (medialtibialplateau-­‐stethoscope and percuss medial malleolus • Fibula?? 11 61 12 62 Other Percussion Tests-­‐With Tuning Fork Fibula, phalanges, radius, ulna, 2bia, MCPs Sensitivity 0.83,specificity 0.80;+LR 4.2,-­‐LRof 0.21 When stethoscope was placed over edema and not tuning fork, sensitivity stayed same, butspecificity increased to0.92; +LR 10.4, -­‐LR 0.18 13 63 Vital Signs & Lab Values VITAL SIGNS Adult: Pregnant Women: >140/99 >140/99 Optimal: slightly below 120/80 Pre‐Eclampsia: after week 20 Normal: 120/80 to 129/84 Eclampsia: plus grand mal seizures Pressure Children High Normal: 130/85 to 139/89 (mmHg) Hypertension Stages Ages 3‐6: Stage 1: above 140/90 Ages 6‐9:: Blood Stage 2: above 160/100: Ages 10‐13:80/50 to 116/76 Stage 3: above 180/110 Ages 14‐19:84/55 to 122/78 Adult: Men Children 90/55 to 126/82 Neonate 90/60 to 142/86 6‐10 year Women : 1 year : 12 ‐ 14 year Heart Rate (bpm) 60‐100 2 ‐ 4 year:70‐190 16 year : 70‐115 : 55‐95 : 80‐160 : 60‐110 Adult Children:: 80‐130 : 55‐100 Neonate 6 year : 10‐20 1 year 8‐10 year Rate 2 year : 30‐40 breaths/min 12‐14 :year21‐26 4 year: 20‐40 16 year : 20‐26 (breath/min) Respiratory : 25‐32 : 18‐22 Adult Newborns:: 23‐30 : 16‐20 2 : 95‐100 40‐90 (%) CV: below 75% Elderly: SpO below 88% results in significant drop 95 *Under Normal Obesity Class Overweight: <18.5 BMI :18.5‐24.9 es: Equation: :25‐29.9 (I) 30‐34.9 [Weight (lbs)/ Height (in)2] x 704.5 (II) 35‐ 39.9 Adults/Child >2 yrs: Hyperglycemia:(III) >40 CV men: <50 or >400 CV women: <40 or >400 ≤ 200 gradual onset extreme thirst, hunger, frequent riskurination,of diabeticdry skin,comanausea, drowsiness, diplopia Child <2 yrs: Glucose Infants: Hypoglycemia: CV: <40 60‐100 (mg/dL) 40‐90 headache, nervousness, shakiness, Blood sleepiness, anxiousness, weakness, confusion, difficulty suddenspeakingonsetperspiration, dizziness, lightheadedness, hunger, riskneuromuscularof insulin shockincoordination HgB WBC Platelets Hct 64 Fx Pt Demographics Risk Factors Sx Investigation Physical Exam Radiographs Advanced Imaging Cauda Equina Syndrome -Intervertebral disk -Bowel/Bladder -Saddle anesthesias MRI herniation -Saddle anesthesias -Gait ataxia -Spondylolisthesis -Sexual dysfunction -Heavy, weak legs -DDD/stenosis Spondylolisthesis Grade 1: < 25% -Numbness -Sharp pain with trunk ext Lateral (neutral, CT Scan -Bilateral pars Grade 2: 25-50% -Tingling -Flexion is easier flex, ext) interarticularis Fx Grade 3: 50-75% -Bowel/Bladder Sx -Traumatic: L5-S1 Grade 4: 75-100% -Degenerative: L4-5 Grade 5: Fallen off Tethered Cord Developing child -Spina bifida Progressive neurological -Progressive neurologic Ultrasound -Spinal cord tumor compromise symptoms -CSF shunt -Weakness -Asymmetric postures -Altered gait -Decreased coordination -Change in bladder function - Progressive scoliosis Vertebral Compression -Pathologic in older - Major trauma (fall/land Possible neuro Sx - ^ kyphosis Traumatic: CT Scan -Anterior vertebral column adults on tailbone) -Tender palpation -Traumatic -Decreased bone - Flexion/axial load density injuries Labral Tear -Men > women -FOOSH -Pain, usually with -Anterior slide test MRI (SLAP tear) -Young (20s-40s) -Compression injury overhead activities -Biceps load test -Traction injury -Catching, locking, -Pain provocation test -Overhead injury popping, or grinding -A sense of instability in the shoulder -Decreased range of motion -Loss of shoulder strength Rotator Cuff Tear -Men > women -Repetitive overuse -Anterolateral shoulder -(+) Drop arm test MRI -Older age (>40) -Age pain -Weak shoulder abduction -Overhead activities -Painful arc between 70 and flexion and 120° of abduction -Weakness in abduction and forward flexion 65 General Risk Factors for Fractures Patient History Medications/Toxins Diseases Potential Complications - Family hx - Alcohol - Acromegaly - Bone Healing - Caucasian/Asian - Aluminum - Ankylosing spondylitis - Osteomyelitis - Female – menopause - Anticonvulsants - Bony metastasis - Pseudarthrosis - 50yr+, >70* - Corticosteroids - Chronic alcohol dependency - ROM Compromise - Low body wt - Cytotoxic drugs - Chronic renal failure - Hemmorage - Immobilization/ inactivity - Excessive thyroxine - COPD - Necrosis - Long-term exposure to - Caffeine - Cushing’s syndrome - Fat embolism toxins, Meds, or Co- - Heparin - Endometriosis - Infection morbidities - Lithium - GI malabsorption syndrome - Complex Regional Pain - Dietary deficiencies - Tamoxifen (premenopausal - Hyperparathyroidism Syndrome (Ca, Vit D) use) - Hyperthyroidism - Supracondylar Fx - Northern European ancestry - Tobacco - Hypogonadism - Brachial Artery - Soft drinks - IDDM - Proximal Humeral Fx - Leukemia - Axillary Nerve - Lymphoma - Multiple myeloma - Multiple sclerosis - Rheumatoid arthritis Clinical Prediction Rules Plain Films: General Guidelines for Use Ottawa Ankle Rules (Modified) Ottawa Knee Rules ● Good diagnostic test for ● Following Ankle/Foot Injury: ● Post knee trauma, 1+ of the traumatic fractures: ○ Tenderness: following: ○ Major trauma ■ post malleolus ● 55+ y/o ○ Minor trauma (compromised ■ tip of malleolus ● Isolated tenderness of patella bone density) ■ mid crest of malleolus ● Tenderness of fibular head ● NOT good for: ■ navicular ● < 90deg of flexion ○ Stress Fractures ■ base of 5th MET ● Inability to WB 4 steps ○ Navicular, Scaphoid Fractures ○ Inability to WB BOTH Specificity: 0.48; Sensitivity: 1.0 ○ Bone Cancer immediately after injury and ○ MSK Cancer during the exam ○ Early Tumors ● Specificity: 0.40-0.46; Sensitivity: ○ Infection 1.0 ○ Tendon avulsions ○ Ligament ruptures Canadian C-Spine Rules Pittsburgh Knee Rules LBP Rules Following head/neck trauma, 1+ of the ● Blunt Trauma or fall AND: ● Suspicious of Cancer following: ○ Age <12 or >50 AND/OR ○ personal hx of cancer ● 65+ y/o ○ Inability to walk 4 steps or more ○ 50+ y/o ● “Dangerous” mechanism of at time of clinic visit ○ unexplained weight loss injury: ● Specificity: 0.60; Sensitivity: 0.99 ○ no improvement w/ 4-6wks ○ fall from 3+ ft or 5+ stairs of conservative therapy ○ axial load to head ● Suspicious of compression fx ○ MVA >55mph ○ 50+ y/o (women); 70+ y/o ○ MVA rollover or ejection (women and men) ○ Collision with RV or Bike ○ Hx of osteoporosis (primary ● Paresthesia in >1 extremity or secondary) ● <45deg of cervical rotation OR ○ Hx of corticosteroid use cannot Specificity: 0.99; Sensitivity: 0.67 safely assess cervical AROM Specificity: 0.45; Sensitivity: 0.99 66 Clinical Screening Tools Percussion Auscultation Tuning Fork Fulcrum Test Ultrasound - Sensitivity: 0.95 - PPV and NPV to predict stress + Patient apprehension - Mixed results - (CI 92-97%) fx (51.4-58.6) - Sensitivity: 0.88-0.93 - Sensitivity: 0.43-0.75 - Specificity 0.86 - 128Hz: Sensitivity (0.70) - Specificity: 0.13-0.75 - Accuracy up to 92-96% - (CI 78-92%) Specificity (0.60) +/- LR: 1-3.72/1-0.27 - Interrater agreement 90.2% +/- LR: 1.75/0.57 (p< 0.0001) - 256Hz: Sensitivity (0.77) +/- LR: 6.8/0.15 Specificity (0.25) +/- LR: 1.03/0.97 - 512Hz: Sensitivity