NPLEX Combination ReviewMusculoskeletal

Paul S. Anderson, ND

Medical Board Review Services

Copyright MBRS

Salter-Harris Fractures:Mnemonics may be utilized to remember the Salter-Harris

classification of epiphyseal plate (physis) fractures.  Out of the five different types, the physis is always involved.  In the first and the last types, only the physis is injured.  

Type I is diagnosed when the physis is widened, distorted, or displaced by traction or shear force.  

Type V is diagnosed when the physis is crushed or compressed by axial compression.  The roman numeral "V" looks like a nut-cracker or crusher, compresser, whereas "I" has a place for your feet (on the bottom horizontal line) and your hands (the top horizontal line).  Picture yourself pulling until the vertical line of the "I" is stretched and the distance between the upper and lower horizontal lines widened.  In the second through fourth types, the metaphysis (M) and/or epiphysis (E) is fractured.  

The key to types II, III, and IV is "ME" twice (Yamamoto).  The first "ME" is separated and the second is together:  M, E, ME.  So, type II = M--metaphysis, type III = E--epiphysis,  and type IV = ME--metaphysis and epiphysis.  Also remember that three has two "e" letters--thr(ee)--and rhymes with "e", so it has to be E--epiphysis.

Radiographic indications and basic interpretation• Cervical Spine

– Jefferson’s Fracture: • Caused by heavy object falling directly on head or hitting head while diving.

Consists of at least two fractures of C1.– Hangman’s Fracture:

• Occurs frequently in a motor vehicle accident or in hangings. It is a bilateral pedicle fracture with anterior displacement of C2.

– Clay Shoveler’s: • Result of flexion injury in the lower cervical spine in which the spinous

process is broken or fractured.

• Thoracolumbar Spine– Chance Fracture:

• Horizontal fracture of a vertebra, usually result of a motor vehicle accident where the seat belt immobilizes the pelvis but the upper body is thrust forward.

– Burst / Compression Fracture: • Collapse or compression of veterbral body, usually caused by fall from a

height.– Spondylolysis:

• Defect in the pars interarticularis, appears as a collar on the “Scottie dog”. Best seen on oblique view.

– Spondylotisthesis: Bilateral pars interarticularis defect.

• Pelvis– Bucket Handle Fracture:

• Fracture through ischiopubic rami on one side and fracture of SI joint on the other side.

– Malgaine Fracture: • Fracture through the ischiopubic rami and SI joint on the same side.

– Avulsion Fracture: • A small piece of bone is separated from the origin or insertion site of a

tendon.

• Upper Limb– AC Joint Separation: X-ray taken with patient holding weights, 3 grades.– Clavicular fracture occurs most frequently in the middle third of the bone.

• Elbow– Radial Head fracture is difficult to see, but look for anterior and posterior

fat pad signs.– Monteggia Fracture-dislocation (night-stick): Caused by receiving a blow

when protecting onself, dislocation of radial head and fracture of the ulna.– Galeazzi Fracture-dislocation: Caused by falling on outstretched hand and

dislocating the distal radio-ulnar joint and fracturing the distal radius.

Elbow Mnemnonic:Policeman Radii Galeazzi tried to hit thief Ulna Monteggia for stealing his bike. Ulna

Monteggia blocked the blow to his forarm and tripped Policeman Radii Galezzi who fell on his outstretched hand.

• Wrist– Colles’ Fracture:

• Distal radial fracture posteriorly displaced.

– Smith’s Fracture: • Distal radial fracture anteriorly displaced.

– Scaphoid Fracture: • Most common fractured carpal bone, may give rise to avascular

necrosis.• Pain in the anatomical snuffbox!

• Hand– Gamekeeper’s Thumb or Skier’s Thumb:

• Fracture of the base of the proximal phalanx of the thumb.

– Bennett’s Fracture:• Fracture through the base of the first (thumb) metacarpal

– Boxer’s Fracture: • Fracture of the 5th metacarpal.

– “Bar Room / Brawler’s ” Fracture: • Fracture of the 3rd metacarpal.

• Lower Limb– Subcapital: A fracture under the head of the femur.

• A common fracture that may lead to avascular necrosis.

– Hip dislocation: • Common MVA injury to have impact on knee when the hip is flexed

(sitting position) which causes the femoral head to be displaced posteriorly.

• 90% of dislocations are posterior.

– Spiral Fracture: • Common femoral, tibial, or fibular shaft fracture.

– Tibial plateau fracture: • Impact most common on lateral side.

– March Fracture: • Stress on the second or third metatarsal.

– Jones Fracture: • Common fracture seen in athletes at the base of the fifth metatarsal.

Bone Scan• Indications (with normal L-Spine XRay)

– Osteomyelitis – Bony neoplasm or metastases – Occult vertebral Fracture

• Mechanism – Radiographic tracer compounds taken up by new bone

• Technetium Tc 99m Phosphate • Gallium 67 Citrate

– Incorporated into hydroxyapatite crystals – Increased uptake indicates areas of high bone turnover

• Advantages – Sensitive for bony neoplasm

• Test Sensitivity in spinal metastases: 85% – Sensitive for infection

• Disadvantages: Non-specific – False positives in 33% older patients (Osteoarthritis) – False negatives

• Diffuse bony metastases • Multiple Myeloma

• Protocols – Technetium Tc 99m Phosphate – Gallium 67 Citrate

• Most accurate imaging in infectious spondylitis (95%) – Single-Photon Emission Computed Tomography

(SPECT) • Three dimensional bone scan imaging • Lesions of vertebral pedicles suggests malignancy

• References – Humphreys (2002) Am Fam Physician 65(11):2299

General M-S Hx Considerations

• What is the functional limitation?

• Symptoms within a single region or affecting multiple joints?

• Acute or slowly progressive?

• If injury, what was the mechanism?

• Prior problems with the affected area?

• Systemic symptoms?

Approach to the M-S examination:• Make sure the area is well exposed - no shirts, pants, etc covering either side -

gowns come in handy • Carefully inspect the joint(s) in question.

– Are there signs of inflammation or injury (swelling, redness, warmth)? Deformity? – As many joints are symmetric, compare with the opposite side

• Must understand normal functional anatomy – – what does this joint normally do?

• Observe the joint while patient attempts to perform normal activity – – what can't they do? – What specifically limits them? – Was there a discrete event (e.g. trauma) that caused this?

• If so, what was the mechanism of injury?

• Palpate the joint in question. – Is there warmth? Point tenderness?

• If so, over what anatomic strucutres?

• Assess the range of motion, both active (patient moves it) and passive (you move it) if ROM is limited / causes pain.

• Strength, neuro-vascular assessment. • Specific provocative maneuvers related to pathology occurring in that joint (see

descriptions under each joint). • In the setting of acute injury and pain, it's often very difficult to assess a joint as

patient "protects" the affected area, limiting movement and thus your examination. – It helps to examine the unaffected side first (gain patient's confidence, develop sense

of their normal).

MUSCULOSKELETAL - MUSCULAR• Duchenne’s Muscular Dystrophy:

– Most common MD of children,– Sex-linked, males,– Muscle replaced by fat / pseudo-hypertrophy of calves

• Gower’s Sign+. – Death by 20 yo commonly.

• Myotonic Dystrophy : Most common in adults.– Presents in adolescence with facial atrophy.

• Congenital Myopathies: “Floppy infant syndrome”– Due to hypotonia. – Nonprogressive disease – unlike the dystrophies.

• Myasthenia Gravis: – Females, antibodies to ACH receptors,

• Fatiguability (worse exertion), • thymomas, thymic hyperplasia, • Tensilon test for dx

MUSCULOSKELETAL – SKELETAL - 1• Osteomyelitis:

– Pyogenic dt staph, hematogenous seeding– Brodie’s abscess=walled off area of bacteria– Sinus tracts develop, squamous carcinoma common at sinus

tracts

• Tubercular osteomyelitis: – Blood borne TB, thoracic & lumbar spine, destructive.

• Osteoporosis: – Primary: menopausal, reduction of bone mass/matrix &

demineralization– Secondary: due to disease (advanced hyperthyroid, PTH Dz.

states…)

MUSCULOSKELETAL – SKELETAL - 2• Osteomalacia:

– Just demineralization of bone

• Osteochondroma: – Most common benign bone tumor.

• Exostoses with cartilagenous covering. • Chondrosarcoma is a risk with multiple lesions

• Paget’s/Osteitis Deformans: – Paramyxovirus– Lytic mixed with sclerotic areas

• Especially skull, bowing of femur/tibia, osteoarthritis, • Pathologic fracture common

MUSCULOSKELETAL – SKELETAL - 3• Osteoma (Benign):

– Normal bone exostosis on skull– If multiple then Gardener’s syndrome=intestinal polyps & sarcomas

• Osteoid Osteoma (Benign): – Tumor of osteoblasts in vertebrae & long bones, young adults

• Osteosarcoma: – Primary bone cancer, adolescent males, familial

• Secondary to Paget’s in elderly, knee, hip, humerus, jaw. – Destructive, mixed lytic & blastic, lifts periosteum (painful)

• Hematogenous spread to lungs, bone, brain. – Second most common primary malignant bone CA.

• Chondrosarcoma:– Malignant tumor of cartilage

• Pelvis of middle-aged men, shoulders, ribs, painful enlarging mass– Most common primary malignant bone tumor,

• Can metastasize, • Ewing’s Sarcoma:

– More common in the young. • Extremely malignant,

– Viscous liquid like pus in marrow, sheets of round cells, • Metastatic

MUSCULOSKELETAL – JOINT 1• Infectious Arthritis:

– GC, staph, strep, TB, Lyme, • Acute painful swollen single joint, fever• Common post trauma.

• Gouty Arthritis: – Hyperuricemia, uric acid in & around joints

• 1st MTP, tophi in olecranon, prepatellar, calcaneal tendon, pinna,

– Genetic, heavy alcohol use. • (DDX: pseudo-gout: Sn/Sx without increased uric acid).

• Ankylosing Spondylitis: – Marie-Stumpell dz, adolescent males– Bony ankylosis of SI & vertebral processes with severe

spinal immobility

MUSCULOSKELETAL – JOINT 2• RA:

– Collagen-vascular dz, females 25-50, RF positive – Nodules at the PIP joints

• Pannus (inflammed synovial tissue), rice bodies (fibrin), infiltrates, vasculitis, Felty’s syndrome=RA, splenomegaly, nuetropenia, deformity,

• Baker’s cyst=outpouching of synovium behind knee, prolonged am stiffness, a

– Arthritis in 3 or more joints, symmetric.

• Osteoarthritis: – Progressive erosion of articular cartilage

• Subchondral cysts, osteophytes, hips, knees, lumbar, cervical, • Herberden’s nodes (osteophytes at DIP), • Bouchard’s nodes (at PIP)

Inflammatory Arthritis and Effusions: • Intense inflammatory processes within the joint space can also cause an effusion.

– Infection, gout, and rheumatoid arthritis are a few of the conditions that can lead to an inflammatory arthritis (IA) and effusion.

• The joint and overlying skin is usually warm and red. In addition, there is significant pain with any active or passive movement.

– The more intense the inflammation, the more severe the pain and the more limited the range of motion.

• Identifying the precise cause of IA is critical as it directs the clinician towards the best treatment, limiting permanent damage to the joint.

– This usually requires aspiration and examination of the joint fluid. • Inflammatory fluid has a high white cell count and should contain other clues as to its origin (e.g.

gout --> crystals on microscopy; infection --> bacteria on gram stain and culture; etc). • Fluid from those with degenerative effusions has relatively few white cells.

• Clinically, patients with DJD have few signs of inflammation and some degree of preserved range of motion (ROM).

– Historical information also helps distinguish DJD from IA. DJD is usually slowly progressive while those with IA more often have an acute presentation.

– Additionally, those with IA may have characteristic patterns of recurrence (e.g. great toe MTP in gout, MCPs of hands in RA), systemic symptoms, suggestive joint deformities (e.g. ulnar deviation of the hands in RA), and particular radiographic changes.

• Of course, it's possible to have element of both IA and DJD. – DJD, for example, can result from joint damage that occurred secondary to past episodes

of gout or infection.

MUSCULOSKELETAL – JOINT-3• SERONEGATIVE ARTHRITIDES:

– Psoriatic Arthritis: RF-, HLA B27+ arthritis; • In 10% of patients with Psoriasis. DIP degeneration.

– Enteropathogenic Arthritis: RF-, HLA B27+ arthritis;

• Patients with UC / Crohn’s (more in UC), • or after Salmonella / Shigella or Yersinia infection. • Symmetric arthritis of Knees, Ankles, Wrists, SI Joints.

– Reiter’s Syndrome: RF-, HLA B27+ arthritis; • Male dominant, post Chlamydia infection• Urethritis / Conjunctivitis / Asymmetric lower extremity

arthritis:– (Knees. Ankles, Fingers, Toes)

MUSCULOSKELETAL – JOINT 4• Chrondromalacia:

– Softness of the articular (Hyaline) cartilage, usually involving the patella

• Apparently caused by unbalancing elements of the quadriceps with patellar misalignment during movement.

• Osteochondroses: e.g. Osgood-Schlatter’s Dz

• Ganglion: – Cystic tumor developing on a tendon or

aponeurosis. – Arises from cystic or myxoid degeneration of

connective tissue.

Ominous Signs• There are a variety of ominous processes that cause low back pain, particularly in

patients > 50. – These problems carry significant morbidity and mortality and mandate a focused and

rapid evaluation (including lab and imaging studies) different from what is required for the relatively benign processes described above.

– Careful history taking and examination can help distinguish these problems. Historical keys include:

• Pain that doesn't get better when lying down/resting. • Pain associated by systemic symptoms of inflammation (e.g. fever, chills), in

particular in those at risk for systemic infection that could seed the spinal area (e.g. IV drug users, patients with bacteremia).

• Known history of cancer, in particular malignancies that metastasize to bone (e.g. prostate, breast, lung).

• Trauma, particularly if of substantial force. • Osteoporosis, which increases risk of compression fracture. More common as

people age, women > men. • Anything suggesting neurological compromise. In particular, weakness in legs

suggesting motor dysfunction. Also, bowel or bladder incontinence, implying diffuse sacral root dysfunction.

– Note: it can sometimes be difficult to distinguish true weakness from motor limitation caused by pain.

• Pain referred to the back from other areas of the body (e.g. intra-abdominal or retroperitoneal processes).

– Could include: Pyelonephritis, leaking/rupturing abdominal aortic aneurysm, posterior duodenal ulcer, pancreatitis, etc.

Inflammatory Arthropathy Labs

• ANA + Reflex

• ASO

• Sed Rate / CRP

• Uric Acid

• RF

• HLA-B27

• Parvo B-19

• Chlamydia…

The Low Back:• Site of confluence of gravitational effect on the

body. – Creates a chronic background stress on these

tissues which goes unnoticed during asymptomatic periods.

• Mixture of muscular, ligamentous, neurological, vascular and other soft tissue structures.– Most tissues are deep, thick and hard to palpate

effectively.

• Many pain patterns overlap.– i.e.: Nerve irritation can be secondary to muscular

or ligamentous inflammation and mimic disc disease.

Vertebral Ligaments

Common Pain Syndromes--Symptoms and Etiology: • Non-specific musculoskeletal pain: This is the most

common cause of back pain. – Patients present with lumbar area pain that does not radiate, is

worse with activity, and improves with rest. – There may or may not be a clear history of antecedent over use or

increased activity. It can “just happen”.– The pain is presumably caused by irritation of the paraspinal

muscles, ligaments or vertebral body articulations. • However, a precise etiology is difficulty to identify.

• Radicular Symptoms: – Often referred to as "sciatica," this is a pain syndrome caused by

irritation of one of the nerve roots as it exits the spinal column. • The root can become inflamed as a result of a compromised

neuroforamina (e.g. bony osteophyte that limits size of the opening) or a herniated disc (the fibrosis tears, allowing the propulsus to squeeze out and push on the adjacent root).

– Sometimes, it's not precisely clear what has lead to the irritation. • In any case, patient's report a burning/electric shock type pain that starts in

the low back, traveling down the buttocks and along the back of the leg, radiating below the knee.

• The most commonly affected nerve roots are L5 and S1.

Common Pain Syndromes--Symptoms and Etiology:

• Spinal Stenosis: – Pain starts in the low back and radiates down the buttocks

bilaterally, continuing along the backs of both legs. – Symptoms are usually worse with walking and improve when the

patient bends forward. • Patient's may describe that they relieve symptoms by leaning forward on

their shopping carts when walking in a super market.

– This is caused by spinal stenosis. • The limited amount of space puts pressure on the nerve roots when the

patient walks, causing the symptoms (neurogenic claudication). • Spinal stenosis can be congenital or develop over years as a result of DJD of

the spine.

– As opposed to true claudication (pain in calfs/lower legs due to arterial insufficiency), pain resolves very quickly when person stops walking and assumes upright position.

• Also, peripheral pulses should be normal.

• Mixed symptoms: – In some patients, more then one process may co-exist, causing

elements of more then one symptom syndrome to co-exist.

Palpation and Examination for Degenerative Joint Disease: • If the knee is injured, start by examining the unaffected side. • Ask the patient to bend the knee, gauging whether they can fully extend and flex

(active ROM) – Full extension is 0 degrees, full flexion ~ 140.

• Place one hand on the patella. – Note any warmth, which if present, would suggest inflammation.– Grasp the ankle or calf with your other hand and gently flex the knee. Perform passive

ROM. – Also, using the hand on the patella, feel for crepitus.

• This is a crackling/grinding sensation that occurs with movement. – If present, it's suggestive, but not diagnostic, of degenerative joint disease (DJD). – It reflects a loss of the normal smooth movement between the articulating structures

(femur, tibia, and patella). – DJD is suggested by the presence of pain with activity that gets progressively more

limiting over time.

• When defining the extent of DJD, the knee is broken into 3 compartments: Medial, central, and lateral. DJD can occur in any or all regions.

• The precise location of the DJD can be hard to determine on examination and is more accurately defined via x-rays.

• If any of the above maneuvers elicits pain, stop and note at what point in the range of motion this occurs.

• It's important to note that many patients report noises (e.g., creaking, popping, cracking) associated with joint movement. The vast majority of these sounds are not clinically significant. Rather, pain or functional limitation are the subjective complaints which carry clinical relevance.

X-Ray of Knee With DJD (Left) and Normal Knee (Right)

• An effusion is the accumulation of fluid within the joint space. – If there is a large collection, the knee will look swollen. – Lesser amounts of fluid can be a bit more subtle.

• The effusion itself makes the knee feel as if it's somewhat unstable or floating and may limit range of motion. – Effusions resulting from inflammatory arthritis (e.g. infection, gout,

rheumatoid arthritis) are associated with other signs of inflammation, including: warmth, redness, pain with any movement.

     Large Effusion, Right Knee.

Ballotment (helpful if the effusion is large) • Slightly flex the knee which is to be examined. • Place one hand on the supra-pateallar pouch, which is above the patella

and communicates with the joint space. – Gently push down and towards the patella, forcing any fluid to accumulate in

the central part of the joint. – Gently push down on the patella with your thumb.

• If there is a sizable effusion, the patella will feel as if it's floating and "bounce" back up when pushed down.

Milking (helpful for detecting small effusions)

• Gently stroke upwards along the medial aspect of the patella, pushing fluid towards the top and lateral aspects of the joint.

• Gently push on the lateral aspect of the joint. – If there's a small effusion, the fluid which was

milked to the lateral aspect will be pushed back towards the medial area of the joint, causing the medial skin to bulge out slightly.

The following are common mechanisms of injury for each of the major ligaments:

• ACL: – Most commonly injured when the foot is planted while extreme rotational

force is applied (e.g. a cleated foot caught in the turf while an athlete attempts to rotate towards that side).

– The ACL may also be injured from a direct force on the lateral knee while the foot is planted.

• PCL: – Much less commonly injured then the ACL. – Posterior force on the tibia (e.g. the tibia striking against the dashboard

in a motor vehicle accident) can lead to disruption.

• LCL: – Direct force on the medial aspect of the knee while the foot is planted.

• MCL: – Direct force on the lateral aspect of the knee while the foot is planted.

Patello-Femoral Syndrome: • PFS is a problem with the way in which the patella articulates

with the femur and moves (tracks) during flexion and extension. – As a result, cartilage lining the undersurface of the patella becomes

irritated and worn down. – AKA: Chondromalacia, this process causes anterior knee pain with

activity and often after prolonged sitting. Several ways of assessing for this condition are described below:

• Have the patient slightly flex the leg to be tested. – Gently push down on the patella with both thumbs, which may elicit pain

in the setting of Chondromalacia.

• Now, gently move the patella from side to side and try to palpate its undersurface. – This may elicit pain in the setting of Chondromalacia.

• Hold the patella in place with your hand and ask the patient to contract their quadriceps muscle. This will force the inferior surface of the patella onto the femur.– Potentially eliciting pain in the setting of Chondromalacia.

Bursitis • Bursa are small pouches of fluid that lie between bony

prominences and the tendons that surround joints. They reduce mechanical friction. The bursa do not NORMALLY communicate with the joint space itself. – Inflammation of the bursa, most commonly due to overuse of the tendon

or direct trauma, can cause pain and swelling.

• Examination of the affected area reveals focal pain. – Swelling, warmth, and redness may be prominent if there is concurrent

infection, another cause of bursitis.

• Bursitis can be distinguished from an intra-articular process because of the location of the pain and the fact that movement of the joint itself does not cause discomfort.

• The major bursa surrounding the knee include: – Pre-patella: Located directly on top of the patella. Most frequently

affected due to direct trauma, as may occur with people who spend a lot of time on their knees (e.g. carpet layers, carpenters).

– Infrapatella (a.k.a. anserine): Below the knee. Also affected by direct trauma, as with the prepatella bursa.

• Lateral Epicondylitis (tennis elbow): Presentation and Anatomy: Extensors and supinators of the wrist insert on the lateral epicondyle of the humerus. Repetitive extension (e.g. back hand motion in tennis, though could be any activity with similar movement) of the wrist can cause inflammation and pain around this bony prominence. Examination is usually remarkable for:

• Pain on palpation around the lateral epicondyle. • Reproducibility of pain with resisted wrist extension and

supination. • Absence of warmth, erythema, or other findings of acute

inflammation.

• Medial Epicondylitis (golfer's elbow): Presentation: Flexors and pronators of the wrist insert on the medial epicondyle. Repetitive flexion of the wrist can cause inflammation and pain around this bony prominence. Examination is usually remarkable for:

• Pain on palpation around the medial epicondyle. • Reproducibility of pain with resisted wrist flexion. • Absence of warmth, erythema, or other findings

of acute inflammation.

Olecranon Bursitis:Non-Inflammatory Bursitis • As a result of repeated trauma (e.g. persistent leaning on elbows), excess

fluid can develop within the bursa, causing it to become very apparent on direct observation.

• Examination is remarkable for: – Obvious swelling at the tip of the elbow. – Absence of pain, redness or warmth, as there is usually a minimum of

inflammation. – Full, painless range of motion of the elbow.

Inflammatory Bursitis As a result of infection (via abrasion to overlying skin) or any other intensely inflammatory process (e.g. gout, rheumatoid arthritis),

• Examination in this case is remarkable for: – Obvious swelling at the tip of the elbow – Marked warmth, redness, and pain on palpation of the bursa. – Range of motion of the elbow is usually preserved. This is one way of

distinguishing inflammatory bursitis from inflammatory arthritis. – Infection within the elbow joint (inflammatory arthritis) is rather rare. When it

occurs, the elbow area is diffusely swollen (ie not limited to the area of the bursa) and there is pain with any flexion or extension of the elbow.

– Rarely, bursitis and/or cellulitis can be so severe that ROM is compromised, making it difficult to distinguish these entities from intra-articular inflammation.

Septic Olecranon Bursitis

Elbow Effusion Caused By Intra-articularInflammatory Process

Carpal Tunnel Syndrome • The median nerve travels through a narrow space when it

crosses the wrist en route to the hand. Occasionally, this space becomes inadequate to accommodate the nerve, placing it under increased pressure.

• The precise reason why this occurs is not clear. Patients usually report some combination of the following: – Numbness and tingling (ie neuropathic pain symptoms) in the

distribution of the median nerve (thumb, index, middle and lateral ½ of ring finger)

– Symptoms are often worse at night, presumably due to tendency to flex wrist during sleep. Flexing puts additional pressure on the nerve.

– Patients will often try to "shake out" their hands in an effort to reduce pain and "increase blood flow" (based on the patient's assumption that decreased perfusion caused the symptoms).

• With increased severity, pain can be present at all times during the day.

• In severe cases, there may be loss of motor strength of the thumb

Ganglion Cyst • Idiopathic, spontaneous protrusion of joint fluid

outside of the articular space. – The cyst is painless and usually located on the dorsal

aspect of the wrist.

• Examination: – Patients often present noting the abrupt development

of a focally swollen area. – There is usually no associated pain or inflammation. – On palpation, the structure has a fluid filled consistency

and is non-tender. – The structure should trans-illuminate when a light is

placed upon it (as it's fluid filled).

Trigger Finger • Flexor tendons connect muscles proximal to the wrist to the

fingers. – When the muscles shorten, they pull on the tendons, causing the

fingers to flex. Occasionally, nodules/irregularities develop along the tendons, which then interfere with their smooth movement thru "pulleys" on the palm.

– Patients note difficulty flexing and extending the affected finger and lack of smooth movement. This is associated with a sensation of sudden freeing of the tendon ("triggering") when the irregularity slips through the pulley.

• Examination: – The palm and fingers usually appear normal. The affected tendon is

not visible. – Ask the patient to fully flex the affected finger. When they attempt to

extend and flex it, the movement will be impaired. It's worth noting that sometimes the triggering does not occur with every movement.

– If you place one of your fingers over the affected tendon, you may feel the "pop" when it finally pulls thru. There is usually no associated pain or inflammation.

ANKLE SPRAINS

• The most common acute sport injuries, 25% in every running or jumping sport

• Mechanism of injury: inversion and plantar flexion of the foot when landing off balance or clipping another player’s foot

ANKLE SPRAINS

• Sequence of injury: anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, musculotendinous units supporting the ankle joint

ANKLE SPRAINS

• Incidence increased in :– individuals with varus malalignment of lower

limbs

– calf muscle tightness

– previous incompletely rehabilitated ankle sprains

ANKLE SPRAINS• Diagnosis: x-rays, stress x-rays

– inversion stress, anterior drawer test– MRI scan in uncertain cases

• Tx: acute phase ( first 72 hours ):– “RICE” Rest Ice Compression Elevation, then

varies according to the severity of injury

GRADE 1 ( Mild ) SPRAINS

• The anterior talofibular ligament affected

– stress: minimal change on inversion, normal anterior drawer

– treatment by encouraging early active movement:• a) stationary cycling• b) walking with protective taping or semi-rigid brace ( Aircast

splint )

GRADE 1 ( Mild ) SPRAINS

c) NSAIDS (anti-inflammatory medication)

d) physiotherapy: electrotherapy, strengthening exercises, propreoception (1 legged stand )

e) functional progression to running, jumping, hopping, swerving and cutting, recovery into 6 weeks

GRADE 2 (Moderate) SPRAINS

• Complete tear of anterior talofibular ligament with some damage of the calcaneofibular ligament

– laxity when inversion, anterior drawer present– treatment: a) 1 week crutches, joint taped or in

aircast splint– follow grade 1 rehabilitation

GRADE 3 ( Severe ) SPRAINS

• Uncommon severe injuries, associated with fractures

– treatment: 10 days NWB in aircast brace or POP, then PWB with the brace up to 6 weeks. Aggressive rehabilitation follows

– surgical reconstruction must be considered

PERONEAL TENDON INJURIES

• Strong everters and weak plantar flexors of the foot

– mechanism of injury:a) associated with lateral ligament injuries

b) forced dorsiflexion with slight inversion and reflex contraction of the tendons ( sprinting, uneven ground, ballet)

PERONEAL TENDON INJURIES

• O/E: Behind lat.malleolus discomfort or swelling. Subluxation on resisting dorsiflexion with eversion

– treatment:

a) acute phase – well-moulded short NWB cast with pad over lat.malleolus

b) chronic phase – surgical correction, POP 4 weeks

c) rupture of peroneal tendons – surgical correction

PERONEAL TENDON INJURIES

TENDINITIS:• occurs in dancers, basketball,

volleyball• combined cause of the lat.malleolus

pulley action and foot malalignment

PERONEAL TENDON INJURIESTendonitis:

TREATMENT –

a) rest from sport, temporary use of heel wedge

b) physiotherapy, extreme cases: local injection into the sheath

c) avoid rapid direction changes or sprinting – 6 weeks

PLANTAR FASCIITIS

• Running on hard surfaces, tennis, netball, jumping

– mechanism: MTP extension produces a “windlass” stress over plantar fascia lifting the longitudinal arch of the foot

– Periosteal reaction may produce a heel spur ( x-rays )

PLANTAR FASCIITIS

• Pain under medial aspect of the heel, worse on tip toeing, early in the morning, stairs

• treatment: – 200,000 IU Retinol daily for 2 months– NSAIDS, 4-8mm heel raise, physiotherapy,

orthotics to modify over pronation

SESAMOIDITIS

• -Sesamoid bones in the tendon of flexor hallucis brevis– dancers, ice skaters, gymnasts, basketball– crush fractures, avulsion, bipartite sesamoid,

osteonecrosis– x-rays and bone scan imaging– shoes with elevated heels avoided, orthotics.

Dancers, gymnasts: adhesive padding and rest, surgical excision

ACHILLES TENDON INJURIES

• Common tendon of gastrocnemius and soleus muscles

• tendon twists laterally from 15cm above insertion becoming more pronounced at 2-5cm above insertion. Blood supply reduced at this level

ACHILLES TENDON INJURIES

• - Etiology factors: lack of rear foot support in shoes, terrain, excessive training loads, biomechanical factors of foot: over pronation, rear foot varus or valgus, pes cavus, tight calf muscles

ACHILLES TENDON INJURIES

• Assessment: ultrasound scan: ruptures, swelling, degenerative cysts, calcifications

– treatment: correct biomechanics with orthotics. Acute phase: rest, ice, electrotherapy, heel raise, gentle stretching, NSAIDS, no inj.

– surgery: ( ruptures, adhesive peritendinitis )

FRACTURES

• Ankle fractures

– talus fracture: surgical treatment to avoid osteonecrosis

– calcaneum fractures: most conservative, early ROM

FRACTURES

• Metatarsal fractures: reduce dislocations, most common fracture 5th metatarsal base ( Jones )

• toe fractures: most treated conservative, strapping with next toe for 3 weeks