Ortho Conditions: Symptoms and Diagnosis Part 3

• Medical Education & Training Campus - Fort Sam Houston: Musculoskeletal disorders study notes

Tenosynovitis

• The inflammation of the tendon and synovial sheath
• Flexor tendons of the hand are most often affected
• May be bacterial or idiopathic as in "Trigger Finger"
• Infectious tenosynovitis is an emergency, and can quickly spread proximally within the involved tendon sheath
• It can cause significant damage to the underlying tendon
• This may result in the spread of infection to deeper tissues

Infectious Tenosynovitis

• Signs and symptoms include pain and swelling of the finger, and pain along flexion tendon
• A focused history should include questions about recent bites/stings/trauma to the finger, and fever/chills
• Physical exam findings include Kanavel's signs
• Kanavel's signs have >90% sensitivity and 50-60% specificity
  • Tenderness along the tendon sheath
  • Symmetric enlargement of the digit
  • Holding the finger in slight flexion at rest
  • Pain along tendon with passive stretching
• Ultrasound may be used as a tool and CBC and inflammatory markers can be considered
• Treatment includes IV antibiotics such as Vancomycin and Ceftriaxone for 7-14 days
• Surgical intervention involving irrigation and debridement of tendon/tendon sheath is often required
• If untreated, infectious tenosynovitis can result in stiffness and loss of function
• Follow-up actions are likely to be directed at hospital discharge
• "Blue Directive": Contact preceptor immediately, may require transfer/admission if infectious

Trigger Finger

• Signs and symptoms of trigger finger include intermittent catching or locking of finger, often at MCP joint
• Possible pain or swelling at palmar aspect of MCP joint
• On physical exam, active flexion/extension of fingers should be assessed
  • A loss of smooth motion of tendon or movement of nodule may be felt when palpating flexor tendon as patient flexes or extends finger
• Treatment includes NSAIDs, immobilization of the MCP joint, and activity modification
• Glucocorticoid injections into tendon sheath by a skilled provider with appropriate credentials is also a method
• Surgical release can be performed if the condition isn't responsive to conservative therapy

Differential Diagnoses

• Dupuytren's contracture results in a constant loss of full extension of the fingers
• Finger sprain: pain generally over lateral surfaces of the MCP/IP joints
• Jersey finger: a tear of flexor tendon (flexor digitorum profundus) generally after forced extension of finger, finger will not fully extend at DIP
• Mallet finger: tear of extensor tendon after forced flexion injury, will not be able to fully extend finger

Ganglia

• Ganglia are cystic swellings near or attached to tendon sheaths and joint capsules
• The cause is unknown, but usually develop spontaneously in adults aged 20 to 50
• They occur most commonly on the back of the hands, especially on the dorsal aspect of the wrists
• Ganglia are the most common soft tissue
• Signs and symptoms include pain described as aching, an obvious swelling in affected area, and may impede ROM
• Size of tumor may increase with activity
• A focused history should assess the impact on Activities of Daily Living (ADL's), ability to perform duties, and pain
• The palpable lesion will typically feel firm, smooth, rounded and rubbery, most commonly on the dorsal wrist
• May be tender
• Ganglia will transilluminate with penlight
• Bone tumor consistency will not be rubbery and soft-tissue tumors do not transilluminate
• Lipoma: soft, painless slow-growing mobile nodule; will not transilluminate
• Reassurance and observation is an option if not causing significant distress as they can spontaneously resolve (50% within a year - UpToDate)
• Temporary immobilization may be used if patient is having pain
• Aspiration of dorsal ganglion cyst is treatment, but should only be performed under direct observation of supervising Medical Preceptor
• Aspiration of a volar ganglion cyst is NEVER recommended and is a surgical problem
• NSAIDs/Tylenol may be used for pain
• Battlefield Acupuncture (BFA)
• Do NOT attempt to “smash it” with a book
• Once resolved, there is a high likelihood it will recur
• Patient should return to clinic if pain becomes unbearable or if symptoms impede ADL's
• Follow-up Actions: Return in 2-4 weeks after immobilization if still in pain and consider non-urgent orthopedics consult if available
• "Blue Directive": Battlefield Acupuncture (BFA), and "Green Directive": Routine review by preceptor, IAW 44-103, No BFA

Lower Extremity Injuries

• Sprains/strains
• Knee pain
• ACL injury
• Collateral ligament injury
• Meniscus injury
• Patellofemoral pain syndrome
• Patellar tendonitis
• Shin splints
• Achilles rupture
• Ankle sprain
• Plantar fasciitis
• Stress fracture

Knee Pain

• The knee is the largest joint in the body and is very commonly injured

• The knees are susceptible to injury from trauma, inflammation, infection, and degenerative changes

• Symptoms include pain, grinding, popping, locking, catching, and/or giving way (or a feeling of instability), swelling, and pain that is worse with activity, such as going up or down stairs

• Focused history includes mechanism of injury, such as plant and twist and patient activities such as running

• Evaluate for tenderness to palpation, swelling/effusion, reduction in ROM, and deformity on exam

• Ottawa knee rules can be applied as appropriate to determine if X-rays are needed

• Ottawa knee rules: radiographs should be obtained after acute injury ONLY for patients who meet one or more of the following criteria:

• Age ≥55 years

• Isolated tenderness of patella with no other bony tenderness of the knee

• Tenderness at the head of the fibula

• Inability to flex the knee to 90 degrees

• Inability to bear weight both immediately and in the emergency department for four steps, regardless of limp

• Differential diagnoses includes:

• Trauma: mechanism of injury and history

• Meniscal injury: location of pain and mechanism of injury

• Ligamentous injury: location of pain, instability, and mechanism of injury

• Bursitis: inflammation and swelling

• Osteoarthritis: chronic degenerative changes to a joint as a result of repeated major or minor trauma

• Patellofemoral pain syndrome: anterior knee pain and chronic

• Popliteal (Baker's) cyst: swelling in popliteal fossa due to enlargement of a bursa that is often secondary to degenerative or inflammatory joint disease or injury

• In the absence of suspected instability or fracture: avoid aggravating activities, gentle range of motion exercises, NSAIDs and Battlefield Acupuncture (BFA)

• Instability or fracture suspected: EVAC or transfer

• Avoid aggravating activities and follow medication regimen if warranted

• Return in 2 weeks if no improvement or sooner if worsening of symptoms

• Follow-up actions include returning in 2 weeks and considering a physical therapy consult, potentially with X-rays if no improvement

• If no progress or worsening of symptoms in six weeks, consider routine EVAC/orthopedics

• "Blue Directive": Battlefield Acupuncture (BFA) and "Green Directive": Routine review by preceptor IAW 44-103, No BFA

Patellofemoral Pain Syndrome (PFPS)

• Also known as “runner's knee", PFPS is characterized by diffuse, aching anterior knee pain
• It is not generally a result of acute injury and is considered an overuse problem
• PFPS pain is exacerbated by climbing or descending stairs, playing sports that exert an axial load like running, kneeling, squatting or after prolonged sitting
• Signs and Symptoms include the following:
• Pain in the anterior knee (“under” the kneecap)
• Pain may also be referred to the medial or lateral patella and through the knee
• Pain with squatting is common
• Swelling is unlikely with PFPS
• Focused History includes the following:
• Recent increase in exercise
• History of trauma
• Activities that cause pain
• Physical Exam findings include:
• Assess for quadriceps or patellar tendon tenderness, warmth or effusion -Quads, hip abductor and external rotator strength compare to unaffected side
• Positive patellar apprehension sign
• Positive patellar grind test
• Crepitus noted with flexion
• Differential Diagnoses
• Patellar tendonitis: pain inferior to patella
• Meniscal injury: tenderness to palpation along the joint line, injury
• ACL injury: effusion of the knee
• Fracture: tenderness to palpation over bone
• Patellar subluxation: positive apprehension sign
• PCL tear: positive sag test, posterior drawer test
• Treatment:
• Stop offending activities
• PRICE
• NSAIDs for pain (short-term)
• Battlefield Acupuncture (BFA)
• Patellar stabilization brace
• OTC orthotics if evidence of pes planus
• Physical therapy is treatment of choice
• Surgery should be an absolute last option and physical therapy is the treatment of choice and should used to maximal benefit
• Follow-up Actions: return in 2 weeks to evaluate for pain, and continue patient exercises for at least 6 weeks
• "Blue Directive": Battlefield Acupuncture (BFA), and "Green Directive": Routine review by preceptor IAW 44-103, No BFA

Patellar Tendonitis

• Also known as “Jumper's Knee"

• A common disorder among young, active adults

• A problem of anterior knee pain

• Differs from the anterior knee pain of PFPS, which is generally a deeper pain

• Pain is noted with sudden loading and usually stops shortly after the load is removed, the pain may be seen at rest in progressing cases

• Symptoms:

• Anterior knee pain, inferior tip of patella

• Pain with exercise or at end of exercise

• Pain with jumping

• Focused History:

• Sport history- sport played, frequency, position, level of performance

• Recent exercise

• History of injury

• Pain with movement

• Physical Exam:

• Tenderness to palpation over the patellar tendon

• Mild swelling over the knee

• Increased heat

• Soft-tissue crepitus

• Differential:

• PFPS: Pain with stairs or after prolonged sitting, pain “deep” to patella

• Meniscal injury: tenderness to palpation along the joint line, injury

• ACL injury: effusion of the knee

• Fracture: tenderness to palpation over bone

• Patellar subluxation: positive apprehension sign

• PCL tear: positive sag test, posterior drawer test

• Treatment:

• PRICE

• NSAIDs for pain (acute)

• Battlefield Acupuncture (BFA)

• ROM exercises/eccentric strengthening (chronic)

• Rest and avoidance of aggravating activities is treatment of choice

• Gradual return to sport/activity

• Follow-up Actions: Return in 2 weeks to evaluate for pain, and continue with physical therapy exercises for at least 6 weeks

• "Blue Directive": Battlefield Acupuncture (BFA), and "Green Directive": Routine review by preceptor IAW 44-103, No BFA

ACL Injuries

• The ACL's primary purpose is to prevent anterior translation of the tibia on the femur
• Can be injured with contact or non-contact injury and is common in skiing, football, basketball and soccer
• Plant and twist injuries are common causes. Hyperextension injuries can also cause -Symptoms and History: -Pain -Swelling around Knee -Difficulty with walking -Feeling of instability -May describe a "pop" -Trauma -Mechanism of injury -Ambulating after injury?
• Physical Exam findings include:
• Limitation of ROM
• Gait changes
• Obvious edema (representative of likely hemarthrosis)
• Positive Lachman’s or positive anterior drawer test
• Utilize X-rays if available to rule-out fracture, if necessary