MSK CCC 1: DDX of Cervical PainCervical Radiculopathy – direct irritation of cervical nerve root from:

Osteophyte, space occupying lesion, increased stress or tension in foraminal area

S/S: Arm painClumsinessPain in Trapezius, Paraspinal, Interscpular musclesDermatomal paresthesias or hypesthesia

Cervical Spondylosis – various degenerative diseases of spine, ankylosis of adjacent vertebral bodies, degeneration of intervertebral disc from:

Age related degeneration, trauma or genetics

S/S: Decreased ROMPain in paracervical, trapezius, interscapular musclesPain with upward gaze or rotation of neck, extension of neck

Progression leads to: Dehydration of the disc, thinning of disc space, protrusion of discBuckling/dysfunction of intralaminar ligamentsAbnormal loading and fxn of joint surfaceCompensatory Changes (ex. Osteophytes)

PE: Spasm of cervical m. knotty or firous texture of musclesLoss of normal cervical lordosisSomatic dysfunction

Cervical Degenerative Joint Disease – degenerative/hypertrophic changes in bone/cartilage of 1+ joints with progressive wearing down of opposing joint surfaces => distortion of joint position

DDX of non-traumatic cervical painSomatic Dysfunction Cervical Spondylosis/DJDCervical Radiculopathy Visceral Referred PainMechanical Referred pain Pathologic FractureInfection

Diagnosis:X-rays: AP/lat/oblique views MyelogramEMG MRI CT

Treatment approach for cervical painOMT, PT, Cervical traction, Medications, Surgical referral

Cervical Dermatomes/Muscle GroupsC5 – elbow flexorsC6 = wrist extensorsC7 – elbow extensorsC8 - finger flexorsT1 – small finger abductors

Hints for PE: If during gross motion testing, the head automatically sidebends and rotates in opposite

directions, think OA &/or Sternocleidomastoid (SCM). If during gross motion testing, the head automatically sidebends and rotates in same direction,

think single SDs (perhaps a few of them). If restriction in flexion, think trapezius; restriction in extension SCM & strap muscles (muscles

that connect to the hyoid). If dysphagia (sensation of swallowing difficulties), think strap muscles and hyoid. If radiation of pain to upper extremities, think entrapment (spondylosis, scalenes, first rib

dysfunction, herniated disc). If radiation of pain to occiput - many muscles, occipital nerves. If headache with pressure and tight headband sensation, think suboccipital and occipitalis

muscles and greater & lesser cranial nerves. Any kind of symptom, think somatic dysfunction. If dizziness or syncope, especially on head turning, think compromise of carotids &/or vertebral

arteries. Be Careful In cases of respiratory disease, think scalenes & sternocleidomastoid (secondary muscles of

respiration) and C3,C4, & C5 (attachment of scalenes and origin of phrenic nerves) If radiation of pain to the ear or jaw, think SCM and stylohyoid

MSK CCC 2: Imaging of spineWhy imagine the spine?

trauma, pain, disturbance in sensation/movement, neoplastic disease workup

Techniques:Plain radiographs

Cervical: AP, lat, obliques, open mouth (c1-c2), swimmer’s (c7)Assess lines on lateral (anterior, posterior, spinolaminar, posterior spinous)

Thoracic: AP, latLumbar: AP, lat, obliques, lateral sacrumSacrum/coccyx: AP, lat, obliques for SI joints

CT + CT thin section - Better for bony structuresNeeded for many thoracic cases because of superimposed structures seen on xrayLumbar – disc or bone abnormality

MRI - Better soft tissue structures: cord, ligaments, discks, marrow

Cervical – axial + sagittal + coronal without contrastThoracic – not good due to pulsating structuresLumar – cord, disc abnormalities, bone contusion, ligamentous injury

Bone scan – look for multiple areas of involvement or unsuspected lesions

Traumatic lesions – most from blunt traumaIndications for imaging: pain, neurologic deficit, distracting injuries, altered consciousness, high risk MOI, vascular injuryInitial screen = plain films, then follow up with a spiral CT

Compression fracture – in thoracic/lumbar spineJefferson Fracture – in bony ring of C1Dens fractures (Type I, II, and III)Flexion teardrop fractureBurst fracture – of C3-C7 from axial compression injury, common to injure cord due to posterior displacement of fragments

Signs of instability:Interspinous, interlaminar widening>50% compression of vertebral body>20° of kyphosis Interpediculate widening>2 mm of translation Dislocation

Degenerative spine disease – major cause of neck and back painCervical between C5-6, C6-7Dessication disk bulge protrusion herniation extruded disk

OsteophytesSpondylolysis – defect of parsinterarticularis

Shows collar on the scotty dogSondylolisthesis – anterior displacement of the upper vertebral body

MC at L4-5 or L5-S1 Extradural processes:

Disc protrusion/spondylosisMetastasis, B9, malignant neoplasmsInfection, Trauma

Intradural extramedullary:MeningiomasSchwannomasEmbryonal tumorsInfection, Trauma

Intramedullar:Demyelinating disease

Tumors: gliomas, ependymomas, hemagioblastomasHydrosyringomyeliaInfection, Trauma

MSK CCC 3: Benign Bone TumorsQuestions to ask in a possible tumor:

Age – certain tumors for certain age groupsDuration of complaintRate of growthPain associated with the mass – B9 are not painfulHistory of traumaPersonal/family hx of cancerSystemic signs or symptoms

Tumors are named by tissue origin and location within the bone:Know: Tumors that recur and tumors that can become BAD

Osteochondroma from bone and cartilage “harmatomas”MC B9 bone tumor that arise near the ends of long bones10-20 years of ageSecondary malignant chondrosarcoma arises in 10%X-ray shows bony outgrowth from cortex (most of tumor is in cartilage cap so opacity on xray is smaller than the mass feels clinically)Tx: Necessary if tumor is near a nerve, causes pain (fxs), disturbs growth or becomes malig

Hereditary multiple osteochondromatosisAD inheritance, lots and lots of tumorsRisk for chondrosarcoma development is higher

Fibrous Dysplasia – defect in osteoblastic differentiation and maturationAny bone can be affected with medullary bone replaced by fibrous tissueAppears “ground-glass” on xrayCT scan can show expansion of the bone due to intramedullary expanding lesion*Monostotic is 7-10x times more common than polyostotic

Associated with systemic conditions (precocious puberty/McCune-Albright/myxomas) Tx: conservative primarily to prevent deformity

Surgical indications: severe/progressive, nonunion, painful, fx

Chondroma – uncommon B9 tumor within bone marrow that forms mature cartilageMen in 2-4th decade, asymptomatic – found incidentally as lytic lesions with stippled calcification when x-rays are taken for something else ~small bones of hand/feet usually

~can be mistaken for chondrosarcomaTx: asymptomatic requires no tx, but need to rule out progressive

Non-ossifying fibroma – nonneoplastic, asymptomaticUsually found in children with 75% occurring in the 2nd decadeFemur > Tibia at juxtaepiphyseal regionLarger lesions presents as a pathologic fractureXrays show lesion migrating away from epiphyseal plate with timeNormally regress spontaneously – treat only if it has a pathologic fx

Chondroblastoma “Codman’s tumor”Rare B9 tumor originating from cartilageSee pain wherever the tumor is, especially at ends of long bonesPeople age 10-20 yearsX-ray: cyst containing spots of calcification that must be excisedTx: sx, bone graft, PT – tumor may recur

ChondromyxofibromaRare, occurs before age 30Located near end of long bonesXray: lytic lesion with well defined margins in the metaphysic of leg

Radiolucent area is a giveawayTx: excision or curettage

Osteoid osteoma – MC benign osteoid-forming tumorPrimarily seen in long bones (proximal femur), classically causes pain at night in young adultsXrays: new bone formation with sometimes a lucent spotTx: NSAIDs for pain

Benign giant cell tumor – in epiphyses and erode bone into soft tissues, known to recurS/S: pain at adjacent joint, visible mass, swelling, bone fracture, limited ROM, fluid

accumulation

Osteoblastoma – selflimited producing osteoid and boneOccurs in vertebrae, metaphysic/diaphysis of long bones, sometimes pelvisS/s: pain of long duration, swelling/tenderness, tumors of the spineBonescan: increased isotope uptake on bone scan

Endochondroma – B9 cartilage tumors Commonly found in tubular bones of hand/foot that may cause unsightly swelling/fxBe able to recognize the radiographs of this for test.S/S: no symptoms but could have hand pain if large tumor/fx

MSK CCC 4: Osteoporosis, OsteoarthritisOsteoporosisIndications that acute back pain may involve underlying conditions

Patient demographics Age > 70 yr History of cancer Glucocorticoid or immunosuppressive drug therapy Alcohol or I.V. drug abuse

Historical features Weight loss Fever Pain increased by rest Bowel or bladder dysfunction

Neurologic symptoms Saddle block anesthesia Progressive motor weakness

Osteoporosis Vertebral FracturesAcute or chronic?Vary in degree from mild wedges to complete compressionDegree of compression does not correlate to amount of painSome fractures could have occurred gradually, and will not cause acute pain

Stable or unstable?Most are stable -- restDiagnosed by spinal radiograph do a DEXA scan to confirm osteoporosis kyphosis or ¯ height

Treatment: NSAIDS, calcitonin, OMT, PT, Educaiton, support groups

Surgery to rebuild their spines:VertebroplastyKyphoplasty

Osteopenia – weak bone that doesn’t necessarily fit the osteoporosis requirementsT score < -1 but > -2.5

Osteoporosis – T-score < -2.5

Risk factors: low calcium, smoking, alcoholism, meds

Age Women Men

Puberty to mid-20s & 30s Bone mass increases rapidly, reaching peak bone mass

Mid-30s to 40s A few years of stability, then slow bone loss No risk factorsbone loss 1% / yr

With risk factors (smokers, inactive) bone loss ³ 6% / yr

Mid-40s to 50s Menopause w/o estrogen replacement, then rapid bone loss ³ 7% / yr for ³ 7 yrs

Mid-50s to late life Continuing bone loss of 1% to 2% / yr

Epidemiology of Osteoporosis Fractures: High prevalence

1.25 million female & 500,000 male hip fractures worldwide (1990) 250,000 hip & 500,000 vertebral fractures in U.S. annually

Causes of Osteoporosis:*Estrogen deficiencyCalcium deficiency & secondary hyperparathyroidismAndrogen deficiencyChanges in bone formation (getting older)Secondary causes/meds (steroids, diuretics, heparin, etc.)

Evaluation:BMD, assess for secondary causes of bone loss, biochemical markersBMD measure – best predictor of fracture if in lowest quartile

DEXA – method of measurement

Treatment: PREVENT! Modify risk factors!Wt-bearing exercise – walking!Ca+2: 1200mg/dayVitamin D: 400-800 IUday regardless of sunlight exposureEstrogen replacement: worried about side effects (PMS-like syndrome), risk of endometrial/breast cancer

Big difference between natural and equine estrogen.Bisphosphonates: stops the resorption of bone

Bad dentition! Do not give! Can cause osteonecrosis of the jaw!Selective Estrogen receptor modulators

Prevent osteoporosisAntagonists in breast/uterine tissue = less risk of cancer development

Calcitonin: hormonal inhibitor of bone resorption

Osteoarthritis/Degenerative Joint disease = MC type of arthritisLayer of cartilage breaks down and wears awayDegree of abnormality on x-ray and clinical findings/symptoms do not always correlate

Spinal – intervertebral disks, vertebral bodies, posterior apophyseal jointsNerve root compression = radicular pain

Degenerative changes:Apophyseal jointSpondylosis – degenerative DISK diseaseSpondylolysis – classic OA change!Spondylolisthesis – one slips forwardSpondylitis

Risk factors:Age – older you get, higher the riskFemale – hand/kneeJoint trauma – more than likely develop DJD in that jointRepetitive stressObesity – highest correlation with knee OA

Pathology:Most striking changes are seen in load-bearing areas of the articular cartilageEarly stages: cartilage is thickerProgression: joint surface thins, cartilage softens, integrity of surface is breachedDeep cartilage ulcers extending to bone

Treatment: Reduce joint loading, exercise, PT, intraarticular therapy, sx, drugs

Spinal stenosisLumbar spine MC in middle-aged/eldery

Classic Syndrome: neurogenic intermittent claudicationRule out: PVD by checking pulses in their feet

S/S: Dull to severe pain in buttocksNumbness, weakness, paresthesias in lower extremitiesRelieved by bending forward, sitting, lying down.Gets worse when going up hills/stairs

Treatment:OMT, PT, wt change, posture change, pain medications with limited usefulness

Inversion tableLaminectomy

MSK CCC 7: Nontraumatic disorders of hand/wristH&PInspection

Carrying angle – normally 10-15° with F > M carrying anglePalpationMotion Testing

Anatomy – bones: Some Lovers Try Positions That They Can’t Handle

Ganglion cystSoft tissue mass of hand/wrist usually attached to a tendon sheath or jointMC scapholunate jointLining herniates out of the ligamentous defect causing a “cyst”

Full of jelly-like fluid due to inflammationS/S: Vague wrist pain, mildly tender mass that may be reducible

Fusiform mass freely mobile, + transillumination, may be mistaken for bony prominenceCommon hx of repetitive wrist loading

Tx: Alleviate symptoms/cause of problemAspiration (seldom curative)Injection with steroidSurgery

Mallet Finger – DIP joint injuryFlexion deformity caused by loss of continuity of extensor mechanism to distal phalanxCommon in 4th/5th digitsMOA: sudden forceful flexion of DIP joint (blunt object)

S/S: Pain, swelling, lack of extension at DIP jointX-rays: Bony avulsion off dorsal proximal distal phalanx + volar joint subluxationTx: Splinting DIP in full extension, encourage proximal joint motion for 6-8 weeks

Surgery if fracture fragment involves >30% of articular surface or volar subluxation

Trigger FingerStenosing tenosynovitis due to repetitive finger flexion in any finger (MC thumb, middle, long fingers)

S/S:X-rays: Not needed

Tx: Avoid aggravating factors, US, local friction massage, NSAIDsCorticosteroid injection every 6-8 wks, splint at nightGets worse – consider surgical release of sheath

Thumb MCP – Ulnar collateral ligament TearTear of UCL of thumb = “gamekeeper’s thumb, skier’s thumb”Hyperabduction of thumb MCP joint (after a FOOSH)Cannot perform an effective pinch

S/S: Pain over UCL area, weak/painful pinchTenderness, swelling over ulnar aspect of thumb MCP

X-rays: Fx associated?Stress x-ray shows >20 of instability compared with contralateral side, complete tear likely

Stener lesion – occurs in complete UCL tearsCannot heal normally residual instability

Tx: Immobilization or functional bracing with MCP in slight flexion for 4-6 wksSx if completely torn

DeQuervain’s TenosynovitisInflammation of the tendons and synovial sheaths, esp 1st dorsal compartment of wristCommon in repetitive motion activities

S/S: Pain in 1st dorsal compartment with gripping/rotational motions+ Finkelstein test

Tx: Splinting in thumb spica, avoid repetitive activity, OMT, NSAIDs, steroid injections*, Sx.

Intersection Syndrome (do not confuse with DeQuervain’s!)“Squeaker’s wrist” – tendon movement is sometimes audibleOveruse injury due to repetitive twisting motions irritation of overlapping tendons

Wt lifters, skiers, canoeists, raking, shoveling

S/S: Pain along dorsoradial wrist worsening with gripping/twisint motionsLocal crepitus with wrist extension

Tx: Avoid repetitive activity, thumb spica split, NSAIDs, OMT, PT/OT, injectionsRarely need surgery

Dupuytren’s Disease – NOT a consequence of activity!!!!Insidious onset of thickening and contracture of the palmar fascia with isolated nodular thickening skin on distal side drawn up into a fold fingers become progressively flexed at MCP/PIP joints

S/S: +Table top test of HuestonTx: Hyperextension exercises of the fingers

With 30° contracture – consider Surgery

Nerve entrapment injuriesCarpal tunnel syndrome– median nerve entrapmentS/S: Tingling in fingertips, nb/pain at night waking the patients referred to elbow/shoulder/neck

+Tinel’s +Phalen’s +EMG +NCVLate findings: wkness of abductor pollicus brevis, atrophy of thenar eminence, l/o sensory in median nerve distribution

Tx: Correction of MOA, splitting wrist neutrally (at night), NSAIDs, OMT, Injections, Sx

Cubital Tunnel syndrome – ulnar nerve entrapment in posterior-medial aspect of elbowMOA: repetitive elbow flexion activitiesS/S: Tenderness in cubital tunnel

+ Tinel’s test +EMG/NCV Wk/sensory loss in intrinsic (ulnar nerve distribution) Tx: Avoid repetitive flexion, PT/OMM/ Splinting/NSAIDs/ Sx

Guyson’s Canal Entrapment – ulnar nerve entrapment medial to carpal tunnelBetween pisiform and hook of hamate

MOA: Repetitive trauma (mass lesion, direct trauma to hook of hamate, cyclists’ palsy, jackhammer use)

S/S: point tenderness, sensory loss of ulnar 1 ½ digitsDDx: hook of hamate fractureTx: rest, OMT, avoidance, NSAID, splint, sx

Triangular Fibrocartilage ComplexMOA: Fall on pronated hyperextended wrist

Twisting w/ palmar rotationRepetitive forced ulnar devianceDistal radius fracture

S/S: Ulnar sided pain, clicking sensationX-rays: Ulnar variance (Positive) – less space so ulnar deviance leads to more traumaTx: Injection* splint/cast, rest, NSAIDs, sx, reduce stressors

Kienbock’s Disease (Idiopathic Avascular Necrosis)MOA: repetitive compressive forces affecting the blood supply

Dominant wrist in younger men and older womenS/S: Vague aching wrist pain with stiffness, tenderness/swelling at lunate, painful ROMX-rays: initially normal eventually collapse of lunateMRI: study of choice for early diagnosis

Tx: Conservative = symptom control, immobilizationFailed conservative = surgical intervention (lunate excision, fusion, revascularization)

MSK CCC 8: Nontraumatic disorders of Forearm, Elbow, and Wrist painH & PInspection

Normal carrying angle = 10-15°Elbow Anatomy

Median nerve passes through two heads of the pronator teres Ulnar nerves through cubital tunnelRadial nerve – divides into superficial and deep branch

Deep branch passes through Arcade of Frohse (most susceptible to injury)PE: ROM, DTRs, muscle testing, special tests

ElbowAnterior PainBiceps TendonitisMOA: repetitive overloading of biceps, result of excessive elbow flexion and supinationS/S: Increased pain on resisted forearm supination

Anterior elbow pain with flexion/supinationWkness secondary to pain, tender biceps tendon to palpation

DDX:Tx: Activity modification, stretching/strengthening/OMM

Rest/ice, NSAIDs, bracing

Posterior painTriceps TendonitisMOA: Overuse due to overloading triceps by repetitive extension (throwing/hammering)S/S: Pain at posterior elbow, tenderness at/above insertion of triceps

Increased pain with resisted extension of elbowX-ray: Could see: degenerative calcification, hypertrophy of ulnar, triceps traction spurDDx:Tx: activity modification, stretching/strengthening/OMM

Rest/ice, NSAIDs, bracing

Olecranon Bursitis “miner’s elbow,” “student’s elbow”MOA: repetitive compression causes irritation to the bursaS/S: Painless swelling of the elbow, no erythemaDDX: Septic bursitis (infxn)Tx: Protection

Aspiration (risk for sepsis), culture if suspected sepsis

Lateral pain Epicondylitis “tennis elbow”MOA: repetitive overuse of wrist extensors, 10X more frequent than Golfer’s elbowRisks:S/S: Aching over lateral epicondyle

Difficulty with wrist extensionX-ray: Ca deposits in extensors due to bleeding from microtears/chronicityTx: Activity modification, stretching/strengthening/OMM

Rest/ice, nsaids, bracing, steroid injections, sx (last resort)

Medial painEpicondylitis “Golfer’s elbow”MOA: repetitive tension overloading of wrist flexorsS/s: Painful inflammation over medial epicondyle, wkness secondary to pain

Tenderness at flexor origin - Tinel’sIncreased pain with resisted wrist flexion and forearm pronation

X-ray: Rarely done, but if done negative except for some calcifications due to microtears DDx:Tx: Activity modification, stretching/strengthening/OMM

MCL (Ulnar collateral ligament) SPRAINMost important stabilizer of valgus stress

MOA: repetitive valgus stress microtears/rupturesPitching/throwing, racquet sports

S/S: Gradual onset of medial elbow pain that is relieved by restTenderness over humeroulnar joint (at sublime tubercle)

PE: valgus stress, moving valgus stress, “milking” maneuverTx: Strengthening/stretching, OMM

Rest, NSAIDs, PTFail rehab reconstruct anterior band of MCL

Ulnar nerve entrapment (Cubital tunnel syndrome)MOA: repetitive elbow flexionS/S: +Tinel’s, Elbow pain radiating to wrist, 4th/5th fingers, +EMG, +NCV

Parethesias on ulnar side of hand, wkness/sensory loss in intrinsic laterTx: Avoid repetitive flexion

Rest, NSAIDs, OMT, PT, Splinting in flexion at night, decompression

Pronator syndrome – pure sensoryMOA: trapping of median nerve between heads of pronator teres

Racquet sports, throwingS/S: Pain, paresthesias, reduced sensation in median n. distribution

Resisted pronation of forearm reproduces symptoms, - Phalens, + TinelsTx: Modification of activities, splinting, OMT, sx

Anterior interosseous syndrome – mostly motorMOA: strenuous or repetitive elbow motion compressing the anterior interosseous (branch of median nerve) by the deep head of the pronator teresS/S: Wkness or loss of flexion of DIP joint of thumb index fingerTx: Depends on cause, lifestyle modification, splinting, PT, OMT, NSAIDs, surgical decompression

If advanced osteophytes can form on the olecranon and in the olecranon fossa

MSK CCC 10: Lupus vs. Rheumatoid ArthritisSystemic Lupus Erythematosus – chronic, recurrent, fatal multisystem inflammatory disorderClinical Findings:

Migratory arthritis and arthralgia that is symmetrical and polyarticular *monoarticular – think infxn*

Predilection for knees, carpal joints (PIP joints)Morning stiffness for minutes vs hours in RADegree of pain > physical findingsTenosynovitis: epicondylitis, rotator cuff tendinitis, Achilles tendinitis, posterior tibial tendinitis, plantar fasciitis

Diagnosis: No single diagnostic markerLupus presents with one or several of the following:

Unexplained nonspecific symptoms such as fever, fatigue, wt loss, or anemiaPhotosensitive rashArthralgia, arthritisRaynaud phenomenonSerositisNephritis or nephritic syndromeNeurologic symptoms (seizures or psychosis)AlopeciaPhelbitisFrequent miscarriages

Laboratory testing:CBC, creatinine, albumin, ESR, CRP, UA, 24 hour urineANA (negative makes it unlikely – good for ruling out, not for positive diagnostic)Antiphospholipid antibodies for hypercoagulability*Anti dSDNA*Anti Smith Abs

*+ abs confirm a diagnosis of SLE

Treatment:1st line for pain + inflammation – NSAIDs or acetaminophen

Contraindicated in lupus nephritis (also COX-2)

Inflammation as prominent feature = NSAIDs (ibuprofen, naproxen, nabumetone)Use with PPI if at risk for NSAID-induced GI toxicity

Pain without inflammation = AcetaminophenContraindicated in liver disease/alcoholism

Hydroxychloroquine (antimalarial) – for joint symptom relief, prevention of clinical relapseFor articular manifestations, rashes, and fatigue

Corticosteroids – used infrequently, only for inflammation – not painRisk of developing osteoporosisGoal – use for acute flare-ups but get dose reduced as quickly as possible

Anakinra – IL1 receptor antagonist – for severe arthritis patients unresponsive to other rxsMethotrexate – resistant inflammatory arthritis

Methotrexate + prednisone = more effective than pred aloneAmitriptyline – TCADs – when pain is unresponsive to other measures

Rheumatoid Arthritis – chronic systemic inflammatory disorder of unknown origin*Causes inflammation of synovium causing chemicals to be released to thicken the synovium/damage the cartilage/bone or affected joint inflammation pain + swelling

Clinical findings: Polyarticular, symmetrical, joints/tendons involved with destruction + synovitisMay be relapsing/remittingSymmetric Joints involved: shoulders, ankles, wrists, hands, elbows, MCPs

Extraarticular findings:Anemia ScleritisFatigue SplenomegalySub-Q nodules Sjogren’s syndromePleuritis VasculitisPericarditis Renal DiseaseNeuropathy

Patho:Joint destruction starting with cartilage erode bone/ligaments/tendons = deformationFibroblasts/monocytes secrete proteinases that break down collagen/proteoglycans

Diagnosis:At least 4 of the following criteria:

Morning stiffness >1 hr, for > 6 wksSwelling of 3+ joints for at least 6 wksSwelling of wrist, MCP, PIP joints for at least 6 wksSymmetric joint swellingHand x-ray typical of RA including erosions/ bony decalcificationRheumatoid nodules (subQ)Rheumatoid factor*

Present in majority of pts (w/o RF may be seronegative, but can still have RA)Labs:

Rheumatoid Factor70-80% of pts, also found in CT disorders/endocarditis

Anti-Citruline containing peptides (CCP)Also seen in active TB

Complications:Joint destructionDeformitiesBoutonniere’sSwan neck’sUlnar deviation Rheumatoid nodulesTendon ruptures Baker’s (popliteal) cyst Tenosynovitis of C1 transverse ligament producing C1-C1 instability/subluxation

Treatment:Early diagnosis + early aggressive treatment!! -- key to minimizing disabilityImmunosuppressing – be more aggressive in treating infxns in these folks!DMARDS (methotrexate, leflunomide, hydroxychloroquine)NSAIDs/SteroidsTNF-alpha agentsPhysical/Occupational Therapy

Comparing Lupus to RA

Feature Lupus Rheumatoid arthritis

Arthralgia Common Common

Arthritis Common Deforming

Symmetry No Yes

Joints involved PIP>MCP>wrist>knee MCP>wrist>knee

Synovial hypertrophy Rare Common

Synovial membrane abnormality Minimal Proliferative

Synovial fluid Transudate Exudate

Subcutaneous nodules Rare 35 percent

Erosions Very rare Common

Morning stiffness Minutes Hours

Myalgia Common Common

Myositis Rare Rare

Osteoporosis Variable Common

Avascular necrosis 5 to 50 percent, often at hip Uncommon

Deforming arthritis Uncommon Common

Swan neck 10 percent, reducible Common, not reducible

Ulnar deviation 5 percent, reducible Common, not reducible

*RA causes EROSIVE arthritis vs. SLE causing a NON-EROSIVE arthritis*

DDX of inflammatory Arthritis:• Infections

Bacterial (Lyme, bacterial endocarditis) Viral

• Reative Rheumatic fever Reiter’s Enteric infections

• Seronegative spondyloarthridities Ankylosing spondylitis Psoriatic arthritis Inflammatory bowel disease

• Rheumatoid Arthritis• Inflammatory Osteoarthritis

• Crystal-induced arthritis• Systemic rhemmatic illnesses

SLE Systemic sclerosis Systemic vasculitis Polymyositis Dermatomyositis Still’s disease Behcet’s syndrome Relapsing polychondritis

• Other systemic illnesses Sarcoidosis Familial Mediteranean fever Malignancy Hyperlipoproteinemias

MSK CCC 11: Trauma to shoulder/elbow Proximal Humeral Fractures

Young high energy & old low energy45% of all humerus fx, 77% occur in female

Consequences/associated injuries:LOM, LOreduction, AVN, heterotopic boneAssociated with (rotator cuff, nerve, vascular, scapula and clavicular injuries

Anatomy: Proximal humerus – broken down in 4 parts

Head, greater, lesser tuberosity, shaftBlood supply to humerus:

Anterior humeral circumflex/*arcuate artery (ascending branch) Posterior humeral circumflex

Nerve damage: Test QuestionAxillary, suprascapular, musculocutaneous (all from brachial plexus)

Muscle damage:Rotator cuff: supraspinatus, infraspinatus, subscapularus, teres minorDeltoid, pectoralis, long head biceps

X-ray Workup:Trauma Series: AP, Axillary, Scapular Y (oblique views)

CT:Articular fractures (impression, head split) & Glenoid fractures

Tx:Closed treatments

Considerations – age, displacement, fxnal demand, arm dominance, ability to salvage with arthroplasty later if needed

Methods:Sling Sling + SwathHanging cast Abduction pillow

ORIF (test question – indications)Indications: Displaced GT fx > 5mm, fx that involves articular surface, surgical neck fx, displaced anatomical neck in young pt, displaced 3-/4- part fractures

Hemiarthroplasty - best for elderly, head splits, AVNIndications – young/middle age with severe head split or extruded anatomic neck OR elderlyTechnique – beach chair position with deltopectoral approach, retain tuberosity fragments,

bone graft from head if necessary

Ends up with unpredictable results from a functional standpoint

Complications of proximal humerus fractureAvascular necrosis – due to disrupted arcuate arteryAdhesive Capsulitis – almost always develops, minimized by early motion and controlled PT

May be fixed with arthroscopic release

Acromioclavicular Joint InjuriesAnatomy

Clavicle – S shaped boneSC joint, AC joint, CC ligaments with muscles attached : SCM, trap, pec major

AC joint – between acromion and lateral clavicle stabilized on all sides by ligaments (superior AC most important)

CC ligs – at distal clavicle (suspend Upper extremity)Trapezoid + conoid = stronger than AC, provide vertical stability to AC joint

MOI for AC jointsModerate/high-energy traumatic impacts to the shoulder

PE:Neurovascular exam (cervical roots)UE motor/sensation + Shoulder ROM

Radiographic Evaluation:AP, Zanca (orthogonal view)Axillary, Stress views

Types of AC separations (for test)Type I – AC ligament sprained with all ligaments/joint/muscles intactType II – vertical displacement, with joint disruptedType III - AC joint dislocated and the shoulder complex displaced inferiorlyType IV - AC joint dislocated and clavicle displaced posteriorly into or through the trapezius muscle, seen on axillary viewType V - AC joint dislocated and gross disparity between the clavicle and the scapula (100-300%)Type VI - AC joint dislocated and clavicle displaced inferior to the acromion or the coracoid process

TreatmentType I/II – conservative with rare surgery for type IIType III – may or may not need acute surgery, conservative tx unless an overhead arm userType IV, V, VI - Surgery

Indications for Late surgical Treatment of AC injuries (if a Type I-III was treated and failed)

Pain, weakness, deformity

Clavicle Fractures<5 mm – acceptable results at 5 years>20 mm shortening associated with increased risk of nonunion, poor functional outcome

TreatmentNonoperative – difficult to reduce clavicle fxs by closed means

They will heal, but are they healing correct? May not have union of fxed endsSimple sling until signs of healing ROM exercises

Plate Fixation – ORIF (open reduction internal fixation)For acute displaced fractures and nonunionsPlate applied superiorly or inferiorly new gold standard

Neurological ComplicationsBrachial plexus symptoms treated by reduction/fixation of fx, resection of callus

Radial Head FracturesElbow Anatomy

3 joints: Humeral-ulnar, humeral-radial, proximal radial-ulnar

Valgus Elbow Stability – from MCL and radial head

MOI – usually a fall with axial load to elbow + valgus forceCould be combined with high energy injuries: elbow dislocation, coronoid fx, collateral lig injury

PE:NeurovascularValgus stress, PLRI (valgus, supination, axial load)Distal radio/ulnar joint stabilityForearm rotation

Radiographic Evaluation:X-rays: AP, Lat, ObliqueMRI: ligamentous injury

Classification: 3 Types increasing in severity – not responsible for these for test

Treatment: radial Head FixationORIF difficulties:

Communition is worse than anticipatedFixation into the head is difficult

Essex - Lopresti LesionsDefined as longitudinal disruption of forearm interosseous ligament, usually combined with radial head fx and/or dislocation plus distal radioulnar joint injuryDifficult to diagnoseTreatment requires restoring stability of both elbow and Distal Radial Ulnar Joint components of injury. Radial head excision in this injury will result in disabling proximal migration of the radius.

Complications of Tx:Improperly placed headwardLoss of fixationPosterior interosseous nerve injuryElbow Stiffness

MSK CCC 12: Thoracolumbar Spine Fractures 90% occur between T11 and L4, with 60% between T12-L2Majority due to MVA

BiomechanicsBurst Fractures – from compressionWedge Fractures – from FlexionFracture Dislocations – from RotationSeatbelt Type Fracutres – from shear

Thoracic spine – stabilized by ribs, MC flexion/compression injuriesThoracolumbar junction– predisposed to rotation/axial compression injuries

B/w rigid thoracic and mobile lumbar spineTL experiences compression when T goes into kyphosis and L goes to lordosisLacks ribs, transition point between Anterior facets and inward facets

ClassificationDenis Three Column Model – to explain injuries/guide treatments

Columns: Anterior, middle*, and posteriorInstability = failure of 2+ columnsMiddle distinguishes 4 types of spinal fractures

1st degree = mechanical2nd degree = neurological3rd degree = mechanical + neurological

Imaging:

Plain film series – most important with lateral being most informativePedicle or TP splayingFracture on lateralVertebral body wideningListhesis

CT – bony anatomyMRI – for spinal cord/ligament anatomy

EvaluationHx – blunt trauma must have spine clearedExam – sans clothes, full neuro exam (rectal tone, perianal sensation), log roll for bruising, deformity, tenderness/crepitus, etc.Imaging

X-rays – AP/Lat for all spinal injuries (excludes the most dangerous pathology)CT – abdomen/pelvis for trauma management, abdominal can pick up TL fxsMRI – upon request, useful for soft tissue and cord injuries

Classification of TL fractures:Flexion-Compression

MC type, failure of anterior column, generally stableTx: Hyperextension orthosis, kyphoplasty, vertebroplasty, sx stabilization

BurstRetropulse into canal + fx of posterior elementsFailure of anterior and middle columns = unstableWidening of intrapedicular distance = decreasd body heightMC T10-T12

Tx: Decompress/stabilize with neurological deficitsWithout neuro deficit – based on stability of fracture

Seat Belt/ChanceHyperflexion-Distraction of posterior elementsMiddle/posterior columns fail

S/S: Posterior tenderness, hematoma, interspinous widening + abdominal injuriesTx: Osseous – bracing

Ligamentous - fusion

Fracture-DislocationAll 3 columns under compression, distraction, rotation, or shear forces

Types:A – flexion-rotation (3/4 with neuro deficit)B – shear (all with neuro deficit)

C – flexion-distraction (3/4 with neuro deficit)Tx: Rapid mobilization and rehab!

TreatmentsOne column = stableTwo columns = mixed, if neuro injury surgeryThree columns = surgery

Decompress neurological elements (remove structures causing compression)Stabilize spineSpine fusionCorpectomy with retroperitoneal flank approach to decompressKyphosplasty for stable compression fractures – relieves pain

MSK CCC 13: Peds UE Disorders Pediatrics vs. Adults

Overuse injuries are commonBones bend before they break

Greenstick fractures, Plastic deformityTorus fracture/Buckle fracture

Peds bones have more collagen/cartilage – improves resilience/reduced tensile strengthMore metabolically active = rapid callus formation, rapid union of fx, high potential to remodel

History – Age is very important for DDXLots of Falls

InspectionPhysical Exam

ROM – supinate, pronate

Ossification Centers of Elbow – growth platesCould look like fracture patterns on x-ray, but may be growth plates that hurtHeal in a clockwise pattern

C - capitellumR – radial headI – internal/medial epicondyleT - trochleaO - olecrenonE – external/lateral epicondyle

Fat Pad SignsAnterior – anatomic

Posterior – pathologic (75% chance of occult fx) – may not see any boney signs, but good chance they have a fracture

MC occult fxs: Supracondylar > proximal ulnar > lateral condyle

Salter-Harris Classification – do not memorize for test, but useful for clinical years

I and V often missed on x-rays

Little League Elbow SyndromeOveruse – due to excessive valgus stress, pain at medial epicondyle MC in baseball, gymnastics

MOI: Overuse/fatigue altered biomechanics medial traction (valgus stress) lateral compression -> microtrauma overuse

Tx: prevention! Rest, ice, NSAIDs, OMM, PT

Radial Head Subluxation/Dislocation “nursemaid’s elbow”MC < 6 years/old, refuses to use arm held in a flexed position against body

MOI: Sudden traction on extended + pronated arm, radial head slips under annular ligament

Tx: Never requires surgery, reduction, arm sling use as tolerated, prevent recurrence

Congenital Radial Head DislocationMC congenital deformity in elbow, found incidentally or following an injury60% have other abnormalitiesTypically lose ability to supination/pronationDoes not necessarily need treatment

Radial Head/Neck FracturesMC 9-15 yrs old, more likely to fracture neck70% have MCL injury at elbow

MOI: FOOSH injuryInspection: Ecchymosis, swellingROM: pain w/ supination/promotion, ↓ROM, crepitusX-rays: AP, lat, oblique, CTMason Classification – do not need for test

Supracondylar Fracture

MC children’s elbow fracture (10% of childhood fx overall)MOI: FOOSH injury (extension injury)

10-20% also have neurologic injury (anterior interosseous nerve is MC injured)Can they make the “OK” sign with their fingers?”

S/S: Swelling, localized tenderness, proximal depression of tricepsX-rays: AP, Lateral (look for anterior humeral line, proximal radial line)Gartland Classification – NOT for test

ComplicationsNeurovascular – nerve damage (median, anterior interosseous, radial, brachial artery)Compartment SyndromeMalunion “gunstock deformity” – due to mal-reduction at time of surgery, cosmetic > functional

Lateral condyle FracturesMC 5-7 years/old

MOI – FOOSH with varus forceS/S: Pain, decreased ROM, localized tenderness

Medial Condyle FracturesMC 7-15 yrs

MOI – acute valgus stressS/S: Ulnar n. injury common

Forearm Fractures – to shaft of radius/ulna (night stick injury)MOI: FOOSH

Monteggia – proximal 3rd of ulna with radial head dislocationMedian/radial nerve injury, presents with obvious dislocation, very complex – needs sx

Distal fractures – 35-45% of all fractures in childrenMOI: FOOSH

Transverse fractures of radius:Colles’ – dinnerfork deformity, dorsal displacement of distal fragment, median n. damageSmith – reverse colles, volar displacement of distal fragment, fall on flexed wristGreenstick – clinical diagnosis, cast with possible of recurrenceGaleazzi – fx distal radius with disruption of radioulnar joint

Congenital Radio-Ulnar Synostosis – do not remember for test

MSK CCC 14: Disorders of Thoracic Spine, Clavicles and Rib cageChest Wall

Costochondritis – chest pain, dull pain worsened by movement/respirationTenderness along costochondral joints, no swellingTx: rest, nonsteroidal meds

Tietze syndrome – rare form often at 2nd rib

*Pectus carinatum

Pectus excavatum – posterior asymmetric depression of the sterum Normal 1st, 2nd manubriumMay cause anterior indentation of the heart, usually comes with congenital cardiac deformities

Poland Syndrome – congenital anomaly, not very commonAbsence of hypoplasia of unilateral pectoralis muscle with syndactyl (fingers grown together)Possible absence of associated ribs

Barrel Chest – AP diameter > transverse diameter, seen in patients with emphysemaRibs become horizontal, sternum forward, senile kyphosis*Expiratory phase inhibited (increased)

Rib Fractures – trauma, osteoporosis, could be palpableSelf-limited, lots of pain 4-6 weeks and then pain disappears

Flail Chest – multiple rib fractures*Develop paradoxical movement of chest wall!Medical emergency, may be associated with pneumothorax, severe trauma

Atrophy of Myopathy of Chest Wall

Cicatrix of the ChestBurns may serious limit chest excursion = decreased respiratory volumes

RicketsVitamin D deficiency multiple bony deformities*Rachitis rosary along chest wall – failure of bones to hardenHarrison groove or sulcus above pot belly

Rib notching – due to collateral circulation intercostals artery dilation from cardiac problemsDilation of arteries wears away the ribsCoarctation of the aorta & Neurofibromatosis*

Dock’s sign – due to collateral circulation 4-8 which anastomose with the internal mammary artery supplying the descending aorta = erosion of costal groove by dilated intercostals arteries

Sternal malformationsSuprasternalForamen with cleft

Cervical Ribs – anomalous accessorib rib (eve’s rib)From C7 transverse processSmall or full rib that can cause impingement syndromes, Thoracic outlet syndromes (+Adson’s)90% are asymptomatic

Bifid ribs – usually not a problem Supranumery ribs (Gorilla rib – 13th)

Thoracic SpineExam: observe, palpate, ROM testing

Thoracic Kyphosis – MC from osteoporosis*No lateral curvativesomeone younger – metabolic/congenital, hyperparathyroidism, ankylosing spondylitis

Osteoporosis and FracturesFrequently in thoracic spine, MC cause of thoracic fx is osteoporosis*Anterior Wedging of vertebral body contributes to kyphosis, not always trauma

Scoliosis – could cause restricted lung diseases if severeWeird AP diameter

ArthritisMC is OA RA – leads to chronic respiratory failure due to spinal problemsPsoriatic

Anklylosing SpondylitisIf seen in thoracic – a late findingHLA-B27, if seronegative worsens with ageInflammatory changes + new bone formation Begins with sacroiliac are and progresses superiorly“poker spine” and *bamboo spine” – causing back pain b/c spine is encased in calciumOther symptoms: anterior uveitis, vascular problems as it’s a connective tissue disease

Clavicle*80% of fractures occur in the middle third which lacks ligamentous supportPay attention to LNs: supraclavicular (gastric ca), infraclavicular

AC Joint Dislocation – tear of coracoclavicular ligamentComplete dislocation = sx

Clavicle Dysostosis – incomplete ossification of the clavicles = abnormalities of shoulders/ rib cageCleidocranial Dysostosis – lack of clavicle development

MSK CCC 16: DDX Acute lumbar PainLow back pain = pain affecting the lumbar segment of the spine

Acute < 3 months, Chronic >3+ months14.3% of new patient visits are for LBP, 13 million for chronic LBP60-90% of lifetime incidence, most expensive cause of work-related disabilityOnly a small % of pts will ever experience lumbar radiculopathy or sciatica as a result of LBP*Strongest predictor for future back pain is a history of prior back pain.

Red flags for a patient with back pain:Major trauma mechanism Age >50 or < 20Hx of cancer Cauda equine syndromeAtherosclerotic disease Use of corticosteroidsHx of osteoporosis Constitutional symptoms

PENo one test, look above/below, palpate, test ROM, do some provocative testsCLUES: pain with backward bending

Radiation or reproduction of pain with certain maneuversDifferentiate between lumbar, sacrum, pelvis, and hip problems

Localize the problem:Standing flexion test seated flexion testDouble leg raise (SI vs. LS)Goldthwaite’s test – SLR + palpation (SI vs LS)

Lumbosacral mechanicsSacrum and lumbar spine move in opposite directionsLumbar flexion sacral extension, etc.Lumbar rotates R sacrum rotates LLumbar sidebends R sacrum takes on an ipsilateral oblique axis

Ligaments and FasciaStabilize, set motion limits (subject to fatigue failure)SI ligaments have mechanoreceptors to gauge strainThoracolumbar fascia transfers load from trunk to legs

Pain Generators:Discogenic StenosisFacet Spondylolysis-listhesisSoft tissue (muscle, ligament, tendon, capsule)

Lumbar testsNerve tension tests:

SLRBowstring/cramLasegueBraggard’s/Sicard’sSlumpNachlasBonnet’sButtock

Malingering testsFlip testHooverAxial compressionSimulated rotation

Acute Lumbar Sprain “Mechanical back pain”Acute injury to soft tissues with no neurologic component85% of patients, never will ID the pain generator

Iliolumbar Ligament SprainRefers pain to anterior thigh or groin, easy to missPalpate or inject for diagnosis

Tx: Acute – OMT, active rest, SI belt Chronic – prolotherapy, ablation, SI belt, OMT

Facet Syndrome – mimics pars fxFocused pain, worse w/ extensionDx: Standing/seated Kemp’s test

Hyperflexion testTx: therapeutic exercise, PT, OMT, prolotherapy

Lumbar somatic dysfunction

Lumbar disc herniation

Usually preceded by bouts of varying degrees and duration of back painPain eventually radiates to the leg (shooting/stabbing)

Dependent on level of nerve root irritation:Higher (L3/L4) groin or anterior thighLower (S1) calf or bottom of footL5 – MC, lateral/anterior thigh and leg pain

Eval: MRI, CT + myelographSurgical indications: cauda equine syndrome, progressive neurologic deficit, persistent bothersome sciatic pain despite convservative management for 6-12 weeks.

Contraindications: unrelenting back pain, incomplete workup, inadequate conser tm

Lumbar DiscitisInfxn of the disc post surgery or from hematogenous spreadIncreasing pain/stiffness + feverEval: MRI, Labs (CBC, ESR, CRP)Tm: Aggressive workup, surgical referral, long term antibiotics

Spondylolisthesis – defect in pars interarticularis that leads to top vertebrae moving more anterior to the one below it, MC at L5-S1, then L4-L5

Type I: CongenitalType II: Isthmic – during 1st/2nd decades

MC occurs at time of adolescent growth spurtFocal back pain and radicular pain with larger slips, some pts are asymptomaticTight hammies, lumbar muscle spasmLarger slips: dermatomal weakness/radiculopathyExtension = provoked pain

Type III: Degenerative F:M = 5:1, >40 years of age, MC at L4-L5Insidious onset pain with radiation to posterior upper thighs, chronic progressiveExtension = provoked pain, sometimes involves reflex changes

Type IV: TraumaticMore likely to have neurologic compromise due to severe slipping

Type V: Pathologic

Grading: 1 – 5 with 5>100% slip and 1 with 0-25% slipRisk factors:

Athletic activityes Congenital defects AgeMC in boys, but females that get it get it worse and probably will need surgeryYounger patients are at higher risk for progression

Do serial radiographs every 6 monthsHigh grade slips require surgery due to pain + neuro compromise

Imaging: Xrays – looking for scotty dog, bone scan, CT, MRI

Tx: PT, Bracing, OMT (NOT in acute spondy), injections, surgery

Lumbar Spondylolysis – defect in pars interarticularis

Pars Interarticularis Fracture – pars fracture“collar on the scotty dog” on plain filmsFocused pain that is worse with extensionTx: active rest, brace/PT, OMT

Lumbar Spinal Stenosis – neurogenic intermittent claudicationMC middle-aged, elderly populationBony encroachment or nonosseous encroachment by ligaments, discs, etc.S/S: begin/worsen with ambulation or standing, relieved with sitting/lying down

Back pain 1st leg fatigue, pain, numbness, wknessEval: Pheasant’s/Homer Pheasants Test

Bicycle Test (neural vs. circulatory claudication)Tx: normally surgical decompression

MSK CCC 17: DDX Hip, Pelvic PainTo develop a DDX:

List of possible diagnosisKnow anatomy and physiologyAppropriate hxPE to match the working diagnosisChoose further work up based on the conditions you think are most likely

Anterior hip painOA Nerve entrapmentInflammatory Arthritis Sports herniaOsteitis pubis Muscle strainsFemoral neck stress fracture TendinosisAcetabular labral tear Referred pain

Osteoarthritis and inflammatory arthritis – Both have gradual onset, morning symptoms, worsening with activity, stiffness (gel

phenomenon) Osteoarthritis tends to have decreased motion on internal rotation and extension Inflammatory conditions are associated with abnormal blood tests ( ESR), white blood

cells in the joint fluid and other joint involvement, perhaps skin or bowel symptoms (rheumatoid usually doesn’t hit the hips)

ancer

Some start with bone: osteoid osteoma, sarcomaSome mets TO bone: breast, prostate, lung, kidney, thyroid

Associated with constitutional symptoms, night pain, original site symptoms

Other causes of Groin PainIntraabdominal disordersGU abnormalitiesReferred lumbosacral pain from lumbar disc diseaseHip Joint disorders

Avulsion Fractures – such a forceful contraction that some bone is pulled off

Common Hip ProblemsGroin StrainHerniasIliopsoas BursitisSnapping Hip

Muscle Strains and Tendinosis

Delayed Onset Muscle Soreness• Diagnosis is by history 24-48 hours after exertion. Muscles are sore. No distinct areas of pain as

in acute strains. Usually bilateral (unless a unilateral overuse – like arm-wrestling…)• Rhabdomyolysis – Can present like delayed onset muscle soreness. Usually associated with

Being immobilized for a prolonged period Acute dehydration with overuse Diagnosis is with a blood test – looking for elevations of creatine phosphokinase (CPK)

Trauma due to Anterior Hip PainGreater Trochanteric BursitisLabral tearAvulsion Fxs

Lateral Hip & Thigh Pain

Common Hip ProblemsHip PointerMeralgia ParethesticaIliotibial Band and Tensor Fascia Latae Syndrome

Buttock and Posterior Thigh PainSciatica

SI joint and LigamentsGluteal strainGluteus medius weakness – due to overuse, associated with SI dysfunctionHamstring strain – due to acute overstretching, running, sprinting

Local pain, deformity, poor ROM & strength

Piriformis SyndromeDislocation – direct blow with hip abducted

Posterior: short leg, hip adducted, severe pain, inability to move, foot points to other legAnterior: abducted, short, points away from other legComplications: Avascular necrosis

MSK CCC 18: Adult hip pain – refer to lecture slides for cases and answers

MSK CCC 19: Congenital/Ped Disorders of Lumbar/Thoracic SpineMyelomeningocele – localized failure of the embryonic neural tube to close properly

Chiari II Malformation

Tethered Cord

Congenital Deformities of the Spine

Congenital ScoliosisIdiopathic ScoliosisLeg Length DiscrepancyInfant and Juvenile scoliosisCongenital KyphosisCongenital LordosisSpondylolysis/Spondylolisthesis

MSK CCC 20: Peds LE disordersRotational Deformities

IntoeingMetatarsus AdductusClubfootTibial TorsionMedial Femoral TorsionOuttoeing

Angular DeformitiesBlount disease

Foot DeformitiesClubfootCavus FootCalcaneovalgus FootPes Planus

Hip disordersDevelopmental Dysplasia of the HipSlipped Capital Femoral epiphysisLegg-Calve-Perthes DiseaseCoxa Vara and Valga

Toewalking

MSK CCC 21: DDX Limping child without feverDevelopmental Dysplasia of the Hip –involve proximal femur/acetabulumF/P: occurs in 1.5% of neonates

Risks: female, +Fa Hx, breech birth, multiple gestation, 1st prego, fat baby, oligohydramnios, clubfoot, caucasianL hip > R hip

Pathophys: early disruption of relationship b/w femoral head and acetabulum, inadequate contact = neither forms normallyCould be due to high levels of estrogen/relaxin in females

Clinical Findings:Ortolani maneuver – to reduce a dislocated hipBarlow maneuver – to determine if hip is dislocatable+ Galeazzi/Allis sign – shortened thigh, decreased adduction

Typical dislocation – majority, in infants w/ no other problems, a developmental disorderTeratologic dislocations – due to underlying NM disorder, occur in utero

Eval:PE! If abnormal Ultrasound in coronal or transverse planes or hip x-raysLines drawn: Hilgenreiner, Perkins, Sheton (disruption here suggest DDH)

Tm: Restore normal relationship b/w femoral head/acetabulumPaclik harness to keep hips in flexion/abduction until clinical/radiographs are normal (<6mos)>6 months – may require a closed reduction

Slipped Capital Femoral Epiphysis – Salter-Harris type 1 fx through proximal femoral physis due to stress around the hipF/p: MC hip abnormality in adolescence

M > F, AA affected more

Just after puberty, associated with fat kidsRisks: Skeletal immaturity malnutrition

Overweight Prior dx of DDH Chemotherapy use Endocrine dxIrradiation Renal failure

Pathophys: Fx is due to stress at growth plate, role in hormones is strong b/c this occurs exclusively during pubertal growth spurtClinical Findings:

50% present with hip pain, 25% present with knee painCould complain for weeks, watch for ddx (acute muscle strain, Osgood-Schlatter, flat feet)Outcome is related to severity of the slip

Eval:H & P, baseline radiographs (AP of pelvis + lateral frog-leg)Obligate ER of hip, soft tissue changes near iliac crests

TM: Stabilization of the hip to avoid further damage to the blood supplyF/U: DJD in middle age,

Legg-Calve-Perthes Disease – avascular necrosis of the proximal femoral head due to compromised blood supplyF/P: mean age 7, M>F, unilaterally most of the time

Risks: Trauma SCFE steroid use sickle-cell crisisToxic synovitis DDH delayed bone age* short stature*

Pathophys:Interruption of blood supply to secondary ossification centers due to rapid growth joint

prone to avascular necrosis replacement with new bone that may appear normal on xray

Clinical Findings:MC: painless limp, may present after exertionIntermittent pain w/ walking or altered gait in children between 4-10, Referred pain to lateral thigh, contralateral knee, gluteal painPain with passive ROM (IR and abduction)

Eval:CBC, ESR for infectionAP, frog-legsBone scan to eval the blood supply

Tm:Protect hip joint! ↓wt bearing, keep femur in Adduct/IR positionkeep head inside acetabulum by bracing or sx

F/U:Short term prognosis is related to severity of disease process or age at onset (older – worse)Long term - OA

Transient Synovitis – arthralgia from inflammation in the synovium of the hipF/P: one of MC causes of joint pain in peds, M>F, between 3-10 y/oPathophys:

Non-specific inflammation of synovial membrane synovial bulging/painMay have hx of trauma or hx of viral infection preceding the joint pain

Clinical Findings:Pain with walking, fever, Hx of recent URT infection↓ROM for AB and IR, hip is tender to palpationNO skin erythema

Eval:Leg Roll Test – most sensitive + with muscle guardingExamine kneeAP/frog leg films show increased joint space↑WBC, ↑ESR – monitor for bacterial joint infectionNeedle aspiration with ultrasound guidance if: temp > 99.5, ESR > 20, severe hip pain/spasm

Check for WBC, Gram stain, culture, ↓glucose in aspirateTm:

Bed rest with no wt bearing, restrict activitiesNSAIDs (ibuprofen, naproxen)Any manipulation of the hip is contraindicated until the diagnosis is confirmed!

F/U: Reeval in 12-24 hoursResolves spontaneously in 2 wks, so if symptoms are still present – check for something else!Recurrence 4-17%, sm risk for OA

MSK CCC 22: Genetic Musculoskeletal Disorders Osteogenesis imperfecta – defects in Type 1 collagen very fragile, brittle bones that break easilyFreq/Pred: MC is Type 1, IV, V and VI are really rare

No known racial/ethnic predilection, no gender preferencePathophys: mutations on loci encoding for alpha1/2 chains of type I collagenClinical Findings:

Type I - onset in infancyA – dentinogenesis imperfecta absentB – dentinogenesis imperfect presentBoth – blue sclera, in utero fractures, kyphoscoliosis, hearing loss, easily bruised, mild,

short statureGrow up normally functioning despite lots of fractures

Type II - onset in utero, do not survive 1st year, most are stillbornDentinogensis imperfecta, blue sclera, NO hearing loss, perinatal lethalitySmall nose, CT fragility, 100% have in utero fractures, short trunk“beaded ribs” on x-ray

Type III - 50/50 infancy and utero with fairly normal life span if they survive early lifeDentinogenesis imperfect, no hearing loss, variable sclera

50% with in utero fracturesLimb shortening with progressive deformityPulmonary HTNTriangular face, frontal bossing

Type IV - onset in infancyA – w/o dentinogenesis imperfecta, B – w/o dentinogenesis imperfectBoth – normal sclera/hearing, angulation of long bones, no bleeding diathesis

Type V and VI – variable onset

Eval: Collagen synthesis analysis to differentiate OI from child abuse/genetic counselingBMD (not proven to be sensitive)Chromosomal gene markersPrenatal testing via chorionic villus sampling

Imaging of skull, chest, long bones, and pelvis as soon as diagnosis is thought of

TM and Management:No medical therapy exists but some experimental use of bisphosphonates has been triedPamidronate, Clodronate – both experimentalSurgical for severe problemsIntramedullary roddingOMT, Genetic counseling

F/u: Educate. Achieve maximal mobility and prevent fractures!

Endochondroma/Enchondromatosis – B9 bone neoplasms that can cause pathologic fxs and painFre/Pred: Risk for malignancy with multiple enchondromas – seen in long/flat bonesPathophys: Ectopic hyaline cartilage resting in intramedullar bone, replace normal bone with

cartilage – look lytic or circular on x-rayPathologic fxs can occur due to “replacement” phenomenonMC malignant tumor associated: Chondrosarcoma

Clinical Findings:Asymptomatic and usually enchondromas cause no problemsWith malignancy – pain, pathologic fxsMay get calcified over time

Eval:Xrays are modality of choiceMRI and CT reserved for further delineationRare to use biopsy or bone scan

Tx:No medical treatment necessary unless they become malignant or cause fracturesPREVENTION!

Subtypes:

Ollier – nonhereditary presenting with multiple enchondromas with unilateral distributionGood prognosis

Maffucci – nonhereditary with multiple hemangiomas and multiple enchondromasMetachondromatosis – multiple enchondromas and osteochondromas

Mucopolysaccharidosis – result of defective lysosomal enzymes, cells accumulate proteins/glycosaminoglycansFreq/Pred: Sanfilippo is 80% of cases, all AR except Hunter which is X-linkedPathophys: By-products of incomplete lysosomal processes build up in tissue and alter cell function

Diagnosis is made by seeing these by-products in the urineEval:

Prenatal diagnosisUA shows excessive excretion of GAGsXrays – basis of diagnosis show skeletal abnormalitiesHead CT to r/o hydrocephalus and an echo to check the heart

Tx and management:No cures – enzyme laronidase for MPSIManagement of symptoms, BM transplant for some

F/U: Prognosis is based on type, but most have a shortened life spanSubtypes:

Hurler – deficiency in alphaLiduronidaseNormal at birth, dx @ 6-24 monthsCorneal clouding, skeletal dysplasia, coarse facial features, lg tongue, short statureDevelopmental delay, hearing loss, hydrocephalusDeath by age 1

Hunter – deficiency in iduronate sulfatasePebbly skin lesions on the back, arms, thighsMild: slower progression with normal intelligence and hearing lossSevere: at age 2-4 y/o, progressive neurological involvement

Retinal degeneration, MR, joint stiffness/deformitiesDeath by 10-15 years

Sanfilippo – deficiency in heparin N-sulftase or glucosaminidaseMC MPS disorder, with 4 subtypesSevere CNS involvement with severe behavioral disordersMental deterioration, lg head, H/S megaly, coarse hair, joint stiffnessDeath by 2nd/3rd decade

Morquio – deficiency in acetyl galactosamine sulfatase or beta galactosidaseOrthopedic problems: spondyloepiphyseal dysplasiaGenu valgum, short status, scoliosis, odontoid hypoplasia, AA instabilityMild: normal life spanSevere: death by age 30

MSK CCC 24: Juvenile Rheumatoid ArthritisFreq/Pred

10-20 cases/100,000 kidsNative Americans have higher incidenceAAs are older when diagnosed, more likely to have +RFPauci/polyart more common in girlsPauci – early childhood, system – any age

Pathophys:True etiology is unknownSynovium has an infiltration of B-cells, plasma cells, monocytes = extra synovial fluid = increased

pressure = distention of the joint capsule = more inflammationCytokines/proteases destroy the joint cartilage breakdown of bone/joint infrastructure

Clinical subtypes:Systemic onset (Still’s Disease)– high spiking fevers several times daily for 2-3 wk period,

may/maynot affect jointsS/S: Very high spiking fever at about the same time everyday

Not responsive to antipyreticsPink rash on trunk/extremitiesJoint swelling does not occur, but arthralgia is common+/- Lymphadenopathy, +/- hepatosplenomegalyDefinitive diagnosis cannot be made until arthritis appears

Pauciarticular – 4 or less joints involved, usually the larger jointsS/S: MC involves larger, wt-bearing joints

Flexion contractures of the jointsMorning limping w/ knee involvement+/- Iridocyclitis/iritis*Include LCP disease, transient synovitis, SCFE and osteomyelitis in differential*chronic involvement atrophy of thigh/hamstring muscles/ligaments

Polyarticular – 5+ joints affectedSubtypes: RH factor + and RH factor –

+ group – arthritis is similar to adult RA with +/- extensor nodule presenceS/S: Lg joints w/ symmetric involvement of small joints in hands/feet

Pain + ↓ROM of cervical spineLow grade fevers

EvalLabs ESR CBC LFTs

UA ANA RFHLA-B27 antigen

For systemic JRA: total protein/albumin fibrinogenImaging:

X-rays of affected joints, bone scan, MRI, CT, echocardiogram

Other procedures:Aspiration, synovial biopsy, pericardiocentesisSlit lamp exam of eye in all children with JRA symptoms of any typeDEXA scan to rule out osteopenia

TreatmentNothing standard, exact is determined by diagnosis and symptomsRequire team approach b/c this involves lots of systems/lifelong problemGoals: Reduce joint pain, preserve joint function, maintain growth, minimize meds and side

effects and minimize osteoporosis. Screen for iridocyclitis to reduce vision problems and maintain function and self-esteem

Meds: NSAIDs, etanercept (TNF inhibitor)

F/U: No prevention, OMT, may need sx with aggressive arthritis, joint replacement

MSK CCC 25: Non-traumatic Foot, Ankle pain – Bolin assignmentsMedial Foot Pain DDX

BoneLigaments/fasciaNerveTendonSomatic dysfunction

Pes cavus – high arch Pes planus – low archArch Assessment:

Inspection Functional (forward squat test)

Functional Arches of the FootLateralMedialMetatarsalTransverse

Posterior tibial tendinitis38-58 year old woman who starts new exercise program and complains of progressive, achy pain in medial arch

Exam: Pain with posterior tibialis MMTUnilateral pronation, PF and inversion

Work up: XrayTx: cast/boot with orthotics

Surgical consult Risk of DJD with ruptureDDx for posterior heel pain:

Haglund’s deformity (retrocalcaneal bursitis)Os trigonum/impingementInsertional tendinitisRetrocalcaneal fat padSever’s DiseaseTrue Achilles tendinitisSomatic Dysfunction

Achilles TendinitisPain in posterior heel that is insidious in onset (stiffness with runnin and in AM)Swelling, nodule or both that migrates proximally with PFAffects 18% of runnersRisks: age, cavus feet, tibia vara, varus deformities, overuse/jumpingTx: stretching of gastroc/soleus

Eccentric exercise

Achilles Tendon RuptureComplication of Achilles tendinitisHx of activity with a sudden pop “like someone shot me in the back of the leg”Hx of fluoroquinolone useDx: Thompson test, palpation, MRITx: surgery

DDX for Heel Pain:Fat pad syndromePlantar fasciitis – morning symptoms related to fascial tension

Pain at medial insertionWindlass manuever

Foreign bodyMedial plantar nerve entrapmentBone bruise/stress fx/fracture

Ddx for pain in metatarsals/phalangesStress/true fxTendinitisInfxn Tumor Synovitis

Metatarsal:Metatarsalgia Interdigital neuromaTurf toe Sesamoid pathologyFriedberg’s infarction

Morton’s NeuromaFibrosis of perineural area of common digital nerve leading to entrapment between 3rd and 4th

metatarsal causing sharp, stabbing, lacinating painWorse when wearing shoes (small toe box size)Dx: clinically, palpation of distal intermetatarsal spaces

Mulder’s signLaseague’s sign

Workup: Xrays to look for osteophytes/massesTx: Conservative injections surgery

March Fracture90% of all metatarsal stress fxs occurring at neck of 2,3,rth MTVery common in runners, or 1st MT in dancersDx: XRAYTx: stiff shoe for 4-6 weeks

5th Metatarsal Stress FxsDistal proximal = stress Jones AvulsionDx: Clinical suspicion, xrays are usually negative, bone scan shows bone turnoverTx: modified rest gradual reintroduction of sport

Sesamoids Injured during running, jumping, typically mediallyDx: Pain on plantar 1st MTP joint, pain with maximal DF with 1st ray

Inability to push off

Bunion – Hallux ValgusValgus deformity at 1st MTP joint associated with shoes with tight shoe boxTx: orthotics, wide toe box, sx when conservative measures fail

Hallux RigidusLimits 1st MTP joint dorsiflexion

MSK CCC 26: Traumatic foot, ankle X-rays involved in a work up:

Foot: AP/Lat/ObliqueAnkle: AP/Lat/Mortise view/Broden views

Fracture Types:Transverse – across boneOblique & spiralComminuted - fragmentedCompound – bone through skin

Fracture Healing:Hematoma soft callus + new vessels osteoblasts lay down new bone (bony callus)

Talar Fractures – relatively rareTalus compressed within mortise (dorsal to plantar shear)Neck fx is most common, complication is Avascular necrosis

Shepherd’s Fracture – due to forceful plantar flexion (confused with os trigonum)Frequently missed (on xray) complications are pain/tendinitisTx: crutches for 6 weeks

Talar dome fracture – injury to articular cartilage/subchondral boneOsteochondritis dissecans (loose body separates and floats in the joint)Prolonged ankle pain after a sprainTx: surgery, untreated leads to DJD

Heel fracture – calcaneal most commonMOI: fall from heightDx: xrays, ct scanTx: compression, elevation, foot pumps, early ROM, sx if displaced

Lisfranc Fx/DislocationMOI: “foot folded beneath me”S/S: pain, edema, ecchymosis, inability to bear weight or push offDx: subtle dorsal disloation of first MTT joint, wt-bearing xrayTx: short leg cast or boot 4-6 weeks

>2 mm separation requires surgery

Toe FracturesMOI: secondary to “stub” or direct impactTx: conservative with “buddy taping”

Tendon injuriesFlexor tendonsExtensor tendonsComplication of missed diagnosis: retraction

MSK CCC 27: Non-traumatic knee pain90% of these problems can be diagnosed with good hx, physical and plain x-rays. MRI is seldom needed. Hx alone can give diagnosis up to 70% of pain.PE:

Peri-patellar palpation, patellar gliding/ballotment, patellar grindJoint line palpationVarus/valgus stress testsMcMurray’s testLachman’sAnterior/posterior drawerPivot shift testOsteopathic eval – “kinetic chain”

Pronation/supinationUnderstand “real world” muscle fxn – econcentric functionInfluence of compensation and accommodation

Imaging: Only needed if H & P do not provide enough infoPlain films

Functional standing xray – shows true alignment and joint space narrowingDo at least 4 views: standing AP, lateral, 30° sunrise for patellar tracking, tunnel view)Asses for arthritis, fracture, growth plate injury, loose body, joint effusion, alignment

Risk factors for Overuse Injury:BiomechanicalAge:

Peds - rapid growth, usually injury to the apophysis (where tendon attaches to bone)Middle aged – inadequate conditioning and flexibilitySenior – look for meds or underlying disease process

Extrinsic Factors:Mechanical, coaching, environment, drug use, training

Classification:Grade I – post activity pain onlyGrade II – pain with activity, does not restrict Grade III – pain with activity + restriction in performanceGrade IV – pain with activity & rest

Tendonitis (chronic or acute)Causative factors: changes in mechanical loading or changes in muscle tendon extensibilityIntrinsic factors: structural failure due to overload, wkness, or a comboExtrinsic Factors: impingement by bone or other structures

“choking the tendon”

Pediatric and Growth IssuesApophyseal injury – traction induced microtrauma at tendon-bone junctionPhyseal injuries – repetitive loading causing metaphyseal ischemica and poor growth in the proliferative zone widening or narrowing of growth plate

Osgood Schlatter’s Disease – common cause of knee pain in active adolescents (M>F 10-14 years)Diagnosis – localized pain at tibial tuberosity, no need for radiographs but they can confirm your suspicion and exlude other causes of knee pain Patho – microtrauma at deep fibers of patellar tendon at its insertion on the tibial tuberosity

“apophysitis”Usually self-limited with resolution at skeletal maturity

Tx – relative rest and enhance strength/flexibility

Popliteal (Baker’s Cyst) – distended bursa in the popliteal spaceMC bursa involved is beneath the medial head of the gastroc or semi-membranous tendonPresent with complaint of aching pain in the posterior knee/proximal calfDiagnosis: AP, lateral, tangential X-rays of the knee

Adults – usually associated with intra-articular pathologyTx: children – may resolve with time, occasionally have to excise

Adults – treat intra-articular pathology first, if discomfrt still remains excise (rare)Lg, tense cysts can be aspirated with common recurrence

Sinding – Larsen – Johansson Syndrome – inflammation of patella at its inferior pole at the origin of the patellar tendon, “traction injury”

S/S: swollen, warm, tender bump below the kneecap Pain w/ activity especially when straightening the leg against force or post vigorous activity, if more severe – pain with any activity

Tx: Ice, stretching, strengthening, exercises, modification of activitiesPatellar band (brace b/w kneecap/tibial tubercle on top of patellar tendon)

Patellofemoral Pain SyndromeMultifactorial: overuse/overload, biomechanical problems, muscular dysfunction

Pes planus (pronation)Pes cavus (high-arched foot, supination)Q Angle – alignment (increased = knocked knees)Muscular causes

Patellar Tracking – tilt, subluxation with inverted J sign, apprehension test, functional evaluationTx: relative rest with temporary change to non-impact activity

Quad strengthening, flexibility (address kinetic chain)Orthotics, icing, knee sleeve

Osteochondritis Dissecans – unknown etiologyS/S: generalized pain with swelling/aching post activity

Intermittent pain/mild swelling that just doesn’t get better (knee sprain forever)MC found on medialfemoral condyle weightbearing surfaceDiagnosis: Tunnel view x-ray with radiolucent defect on femoral condyle, confirm on MRI

Tx: Rest, period of non-weight bearing or sx if necessary

MSK CCC 28: Traumatic Knee PainBone TraumaPatella Fracture

Tx: ORIF > 2mm articular displacement

Tibial Plateau fracture (wt bearing surface of proximal tibia)Tx: >3-5mm, surgery requiredKnee joint unstable, fx is open, compartment syndrome surgeryAlso fix meniscus injury that may have occurredLateral fx can be arthroscopically reduced and treated with leg screwsMedial fx require a buttress plate and screws

Distal Femoral Condyle Fxs and Supracondylar Femur Fractures

Avulsion of Tibial Spine or “bicycle” fracture in children

Soft Tissue Trauma – rare to occur in childrenKnee Ligament Tears

Internal: ACL/PCL will not heal on their own (ACL more commonly repaired – must do a graft)Recovery takes 6 months External: MCL/LCL – heal on their own

Meniscus Tears – require major trauma at young ages, but minimal twisting/squatting if >35 yearsS/s: Pain along joint line, stiffness, mild swelling or knee with or without locking/catching

Audible popping with flexion/extensionRepair is one of the top 3 orthopedic surgical procedures done in USRepaired with sewing/stapling if the tear is in the right locationTransplant cadaver menisci but unproven efficacy

Articular Cartilage DamagePoor healing potential, nearly always leads to arthritisRepair techniques:

Trimming/contouring of torn surfaceAbrasion/micro fracture in an attempt to grow fibrocartilage repair cartilageFilling a contained defect with cartilage and bone grafts from elsewhereGrowing autologous cartilage cells in tissue culture and implanting them

Combos of the above + Knee DislocationPatellar Tendon Rupture

Suturing tendon back to patella with large and strong sutures – very successful if done acutely

MSK CCC 30: Bone, joint infections – Palmieri

Review cases

MSK CCC 31: Traumatic injuries to wrist/forearmDislocation – bony components of joint are no longer in contact with one another/complete disruptionIncomplete fx – Greestick or TorusSubluxation – bony compartments are partially in contact with one another/partial disruption

Description:Direction of fx line

TransverseDiagonal/obliqueSpiral

Relationship of fragmentsDisplacement/Translation – sideways motion of a fxAngulation – amt of bend at a fx lineShortening – amt a fx has collapsed/bayonet oppositionRotation

# of fragments2 – simple2+ - comminuted

Communication with atmosphere (best evaluated clinically)ClosedOpen

Gustilo classification used for prognosis

Treatment:ImmediateDebridement of skin, muscle, bone, tendon

Colle’s FractureOf the distal radius with dorsal angulation

Jones’ FractureFx of base of 5th metacarpal

Boxer’s FractureFx head of 5th metacarpal with volar angulationMOI: punching a person/wall

Fractures in ChildrenSalter-Harris classification (kids fx that involve the growth plate)I: across the physis with no metaphysical/epiphysial injuryII: across the physis with extends into the metaphysisIII: across the physis which extends into the epiphysis

IV: fx through metaphysic, physis and epiphysisV: crush injury to the physis

Supracondylar Humerus Fxs

Distal Radius FxsCommon with high potential for functional impairment and frequent complicationsMost often result from a FOOSHDx: Xrays – look for dorsal/volar rim, look for die-punch lesions of scaphoid/lunateTx: Closed reduction