MSK Final Review PDF

Pathology Basic Info MOI (if listed) Treatment Complications...

Pathology Basic Info MOI (if listed) Treatment Complications OR Special Tests Proximal Humeral Fracture Fracture presents at the proximal humeral powerful medial rotation and Rest is the primary treatment, AND education to STOP throwing “Little Leaguer’s Shoulder” growth plate adduction traction force on the initially Throwing sports humeral epiphysis that occurs Rehabilitation is designed to improve ROM, strength, endurance, and Result is a stress fracture (Salter Harris Type I during deceleration phase of proprioception or II) throwing or pitching, with Careful attention MUST be placed on re-introducing stress, especially Imaging shows widening of the growth plate rotational forces during arm throwing and demineralization of the metaphyseal cocking and acceleration phases side of the physis compounding the problem Athlete complains of acute shoulder pain when trying to throw hard Proximal Humeral Fracture in In the elderly, proximal humerus fractures Initial period of immobilization (sling) is usually recommended (2 Comp: Rotator cuff Elderly usually occur in individuals with osteoporosis weeks) for stable nondisplaced fractures and 4 weeks for nondisplaced tears, axillary nerve and women are affected twice as much unstable fractures followed by gentle AAROM exercises and damage, stiffness Most occur with minimal trauma, such as strengthening when the fracture is healed FOOSH from standing height, or a direct blow to the lateral aspect of the shoulder Most fractures are non-displaced and treated conservatively, versus serious displaced, intra-articular fractures, which are treated with ORIF, a hemi-arthroplasty, or a TSA. Most common fracture pattern is a displaced or nondisplaced (one part or two part fracture) involving surgical neck Clinical presentation is pain, swelling, and tenderness about the shoulder as these are acute injuries Clavicle Fractures Most common reported fracture of the direct blow from a fall onto the Goal of treatment is to minimize the risk of nonunion and malunion shoulder girdle affected shoulder, OR an impact Sling immobilization for 2-3 weeks to develop clinical union and then Incidence highest among children and such as a tackle in football physical therapy consisting of ROM and strengthening of the adolescents surrounding shoulder muscles 87% occur from falls onto the shoulder, Direct blow – compressive force Healing range from 6-9 weeks in young children to 8-12 weeks in adults direct impact 7%, FOOSH 6% causes buckling of the clavicle Basic classification: leading to a fracture once the o Group I: middle 1/3rd ~ 80% compressive force exceeds the o Group 2: distal 1/3rd ~ 17% tensile strength of the clavicle o Group 3: medial 1/3rd ~ 2% ACJ Pathology/Sprains ACJ is inherently unstable Direct trauma to the point of Treatment ST: AC resisted Grade I-III Grade I: a sprain of the AC ligaments, no the shoulder; FOOSH o Conservative for grades I-II horizontal extension, displacement o Conservative / surgical III ACJ compression, X- Grade II: a tear of the AC ligaments and a o Surgical for grades IV-VI body ADD (passively), sprain of the CCL ligament, mild to O’Brien Rehabilitation moderate displacement o Grade I: sling for 5-7 days, NSAIDs, PT, return to activities 1-2 Test-item cluster: (AC Grade III: a tear of both the AC and CC weeks extension, X-body, ligaments, true dislocation with damage to o Grade II: sling for 2 weeks, NSAIDS, PT, return to activities 3 O’Brien) the deltoid and trapezius attachments weeks Sp: 97%; Sn: 25% o Grade III: sling 4-6 weeks, NSAIDS, PT, return to activities 6-8 wks Scapular Fractures 1% of all fractures, 5% of fractures involving Most treated non-operatively with 7-10 days of sling immobilization the shoulder followed PROM and AAROM exercises progressing to strengthening once sufficient radiographic healing is demonstrated Subacromial Impingement progressive orthopedic conditions as a result ST: Neer Impingement of biomechanical faults and/or structural Test, Hawkins abnormalities (shape of acromion) Kennedy Test, Jobe 44-65% shoulder pain Empty Can Test Peak age 45-64 Test-item cluster: +LR Exam: 10.54 (Positive Night pain Hawkins Kennedy, Pain with movement (anterior/lateral Positive Painful Arc, deltoid/arm) Infraspinatus test) Loss of GH IR o Humeral head retroversion o Posterior capsule hypomobility o Shortness posterior cuff from repetitive eccentric forces Weakness in ER/AB Painful arc Painful palpation of RC tendons Limited AROM / Full PROM Positive impingement/RC special tests Pectoralis minor shortness SCAPULA MOBILITY: Decreased posterior tipping, Decreased upward rotation HUMERUS MOBILITY: Decreased posterior translation, Increased anterior translation Rotator Cuff Tear Affect 20-28% individuals 60-69 years old Group I: all chronic full-thickness tears in an older age group (>60 ST: Jobe Empty Can, Affect 31-41% individuals > 70 years old years) and irreparable tears à initial conservative treatment ER Lag Sign – infra, IR Affect 51-62% individuals > 80 years old Group II: All acute tears >1cm and all chronic full-thickness tears ( 90 degrees of flexion o Arcade of Struthers o Avoidance of valgus stress at the elbow o Fascia of the FCU o Impairments o Proximally at pectoralis minor Operative o Distally at Guyon’s canal o When conservative management fails Symptoms: paresthesias, clumsiness of the o Evidence of muscle atrophy hands or loss of coordination, non-painful o NCV of < 39m/s across the elbow snapping during active and passive elbow flexion and extension Pronator Teres Syndrome High median nerve entrapment in the insidious onset associated with Non-operative: 50-70% success rate pronator teres repetitive pronation and o Patient education regarding rest, immobilization, and aggravating Sites of Compression: supination of the forearm factors o Between the two heads of the usually seen in office workers, o Splinting is 90 degrees of elbow flexion in neutral forearm pronator teres manual workers, musicians, position during the day artists, athletes o Between the FDS and FDP o Impairments Symptoms: vague anterior elbow pain, may be weakness in the thumb, index and middle fingers, symptom reproduction at the border of pronator teres with compression Anterior Interosseous Nerve Entrapment of a branch of the median nerve Non-operative: Entrapment at or distal to the elbow o Patient education regarding rest, immobilization, and aggravating New research is suggesting it may be an factors immune mediated inflammatory response o Splint is placed posteriorly in 90 degrees of elbow flexion in Symptoms: 8-12 hours of deep forearm pain neutral forearm position during the day that resolves, symptoms are intermittent o Impairments initially and then become more consistent and debilitating Main sign is the inability to make OK sign, which is indicative of decreased motor function in the FPL and FDP tendon 1 Complete palsy of the AIN presents with no motor function of the FPL, FDP (digits 1 and 2), and pronator quadratus No sensory symptoms Radial Tunnel Syndrome Deep aching distal to the lateral epicondyle Pain at the belly of the brachioradialis Pain with resisted supination Pain with repetitive wrist flexion and/or pronation No motor or sensation loss Posterior Interosseous Nerve Lateral forearm or elbow pain Syndrome Pain with wrist extension and RD Weakness of finger extensors Thumb extension elicits pain at the lateral epicondyle of the humerus No sensation loss  Pathology Basic Info MOI (if listed) Treatment Complications OR Special Tests Mallet Finger Also known as baseball finger or terminal sudden passive forced flexion Splint for 8 weeks or ORIF extensor tendon injury event in which the extensor Involves extensor mechanism of DIP most tendon is compromised (sliding often digit 3 into a base with finger extended) Avulsion of collateral bands of EDC and / or a fracture Exam reveals no active DIP extension, while passive flexion is full Jersey Finger Flexor tendon injury forced passive extension Orthopedic referral is a priority Avulsion and/or rupture of the FDP most moment placed on distal aspect often middle or ring finger of the digit, during active finger Exam: finger may appear straight as there is flexion (grabbing a jersey) unopposed extensor tone IP Collateral Injury Abduction or adduction force Partial tear: swelling, immobilization in extension for 3 weeks Dislocation: reduction by traction, immobilization in extension for 3 weeks, recovery 6 months - 1 year Dequervain’s Syndrome Inflammation (tenosynovitis) of APL and EPB Repetitive motion of RD and Splinting (thumb spica) (first dorsal compartment) wrist extension Steroid injection Finkelstein’s test Surgical release CFM Manual therapy Eccentric strengthening Triangular Fibrocartilagenous Meniscal disc provides cushion between ulna Treatment is conservative or surgical Complex (TFCC) Tear and triquetrum Surgical: repair if peripheral, removal if central Blood supply similar to knee menisci Traumatic vs. degenerative tears Symptoms: pain, clicking PE: press test Entrapment Neuropathies Carpal tunnel formed by carpal bones and ST for CTS: transverse carpal ligament, leads to thenar Phalen’s Test, Reverse atrophy and sensory loss Phalen’s Test, Tinel’s Ulnar nerve: stretched in a valgus deformity Test (CUBITAL TUNNEL) Radial nerve: axilla compressed by prolonged use of crutches, pain, paresthesia, weakness of finger and wrist extensors Thoracic outlet syndrome: compression of brachial plexus and/or subclavian artery Dupuytren’s Contracture Contracture of palmar fascia Stretching ST: Finklestein’s Test Unknown etiology Surgical removal of involved fascia Middle and Proximal Undisplaced: “buddy taping” Phalange Fractures Displaced: closed reduction with aluminum splint, or ORIF Displaced intra-articular: ORIF Boxer’s Fracture Fracture of 5th metacarpal neck Closed reduction and immobilization in flexion for 3 weeks Metacarpal head is depressed and ORIF for unstable fractures posteriorly angulated Bennet’s Fracture Fracture – dislocation of 1st CMC joint Closed reduction and cast providing compression to base of the metacarpal, Comp: or ORIF Articular incongruity can lead to DJD Gamekeeper’s Thumb Tear of ulnar collateral MCP ligament Partial tear: splint for 2-3 weeks ST: Ulnar Collateral Can also involve a piece of bone (avulsion) Complete tear: surgical repair, recovery 4-6 months Ligament Stress Test Neglected tear: weakness of pinch Carpal Instability Dorsal intercalated segment instability (DISI) o Scapho-lunate dissociation Ventral intercalated segment instability (VISI) o Lunato-triquetrum dissociation Scaphoid Fracture Most common missed fracture on fall on outstretched arm, wrist Immobilization of ORIF if non-union radiograph extended and radially deviated Poor blood supply to area Arthritis CMC joint of thumb ST: CMC Grind Test for o Most common site of OA OA OA – PIP/DIP o Herberden’s nodes – DIP o Bouchard’s nodes – PIP RA – MCP o Boutonniere deformity o Swan neck deformity o Ulnar drift