Ortho Study Guide FINAL

7/24/2019 Ortho Study Guide FINAL

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Diagnosis and Treatment of Orthopedic Disorders

1. Discuss the signifcance o the elements o historyor orthopedic complaints and correlate injury or condition tohistory o trauma

Age

Sex

Occupation

Socio-economic background

Family history

Past medical history P!"x# D!$ inection$ trauma

"O%$ %"&$ %"'($ %"')'

P*)S+

,haracter

%hen frst noticed and by hom

Association ith knon injury or disease

.ncreasing

'xtent o disability

Obser/ation- gait$ posture$ disrobing$ acial

expressions not alays dependable#

.nspection- alignment$ deormity$ selling$

erythema$ symmetry$ skin color$ atrophy

Palpation- pain$ masses$ deects$ muscle

tone0bulk

!otion- compare to uninjured side or range$

crepitus

Strength0Stability- muscle groups and isolated

joints

Nerves

Median tea drinking

Ulnar Intrinsics

Radial Wrist extensors

. 'xplain the indications$ contraindications$ positi/e fndings$ andlimitations o the olloing studies1

a2 Plain radiographs$ tomography$ and contrast radiographya2Fracture assessment$ sot tissue abnormalitiesb2Anterior0PosteriorAP#34ateral5 minimal /iesc2Obli6ue-sometimes useul$ not alays necessary

b2 7ltrasound scanninga2D8+$ !asses$ neborn hip dysplasia2 9ood or identiying superfcial tissue problems$ including

tendinopathy and syno/ial problemsc2 )adioisotope scanning

a2:one scan-technetium-;; Occult0stress xs#b2+agged %:,s- indium-


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a2 type o radiographicexamination that uses a contrast medium to detect pathologyo the spina

cord$including the location o a spinal cord in!"r#$ c#sts$ and t"mors2 +he procedure oten

in/ol/es injection o contrast medium into the cer/icalor lumbar spine$ olloed by se/eralB-

rayprojections2 A myelogram may help to fnd the cause o pain not ound by an !). or ,+2

b2!yelography has been largely replaced by the use o ,+and!).scans2

l2 Arthrograma2An arthrogram is a series o images$ oten B-rays$ o ajointater injection o a contrast medium2

+he injection is normally done under alocal anestheticb2Patients ho are allergic to or sensiti/e to medications$ contrast dyes$ local anesthesia$ iodine$

or latex should not ha/e this procedurem2 P'+ scan

a27seul in identiying metastatic malignant lesionsb2A positron emission tomography P'+# scan is an imaging test that uses a radioacti/e substance

called a tracer to look or disease in the bodyn2 Arthrocentesis

a2 +o rule out inxnb2,. i .()C2E

%. 4ist the six common non-operati/e methods o treatmento orthopedic conditions and correlate one clinicalscenario to each treatment modality

a2 !odifcation o acti/ities $ .ce$ ,ompression$ 'le/ation ).,'#b2 !edications- PO$ .njectable- tendinitis

c2 +herapy- adhesi/e capsulitisd2 .mmobili=ationa2:races$ splints$ appliances- carpal tunnel syndromeb2,asts- plaster$ fberglass- broken bones

e2 +raction- shortened$ closed x o metacarpal2 !assage- sore musclesg2 Acupunctureh2 Osteopathy

&. Defne the olloing surgical inter/entionsand list to indications and complications o each1a2 Syno/ectomy

a2 Surgical remo/al o syno/ialmembrane o a syno/ial joint2

b27sed in arthritis that isreractory to medications

b2 Osteotomy

a2 A bone is cut to shorten$lengthen$ or change itsalignment

b2 7sed in "allux /algusc2 Arthrodesis

a2Fusion o a jointb2 7sed to treat pain caused by

the motion or instability o thespine

d2 Arthroplastya2oint replacement or reshapingb2 7sed in se/ere arthritis

e2 :one gratinga2Autograt-sel$

homograt5allograt0xenograt$

heterograt-di>erent species2 +endon grating

a2 )eplacement o torn tendon inA,4 tear2

g2 '6uali=ation o leg strengtha2 Strengthening o leg that hasn@t

been used or example in anee replacement

h2 :iopsya2+o check or cancer in bones

'. Discuss the indications or rehabilitation olloing orthopedic surgery2a2 +o restore muscle strength and mobility2 +o increase blood ?o to areas and to promote healing2

(eneral Orthopedic Disorders

1. Discuss the di>erences beteen congenital and ac6uired deormitiesa. ,ongenital5 abn de/ present at birth2Occurs rom1

i2 'mbryonic de/elopmentii2 7terine malpositioniii2 !edicationsi/2 9enetic deects/2 'n/ironmental in?uences

/i2 ,ombination o abo/e

). Ac6uired5 arising ater birth and may ormay not be progressi/e

i2 !edicationsii2 9enetic deectsiii2 'n/ironmental in?uencesi/2 ,ombination o abo/e

. 4ist the top G types o bone dysplasias and malormationsa. ,luboot

i2 !ost common


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or clubootii2 +x5none

c. *ip d#splasiai2 Dislocation due to

7nder de/elopmentii2 FemalesCmalesiii2 D04 may occur ater birthi/2 +x5 reduction$ +avlik )race$

castingd. Spina bifda

i2


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,hronic1 ,hronic atigueo P' Findings1

9uarding and limited use o a>ected limb /ocal )one tendernesso/er area o inection Acute /s2 chronic

Acute1

4ocal edema$ erythema$ calor armth#$ and tenderness

4ong boneL)estriction o mo/ement

8ertebralLFailure o young child to sit up normally

,hronic1

(on-healing ulcer

Sinus tract drainage

.ncreased local paino 4ab0 )adiologic '/aluation- Findings1

,:, 0%:, and di>erential B-ray AP and lateral#Limportant to r0o other conditions ,an confrm 0 bone scan$ indium scan$ !). or ,+ (eedle aspiration ,ulture o ound sabLlimited use ith bacterial causes :one biopsy re6uired unless hematogenous osteomyelitis ith 3 blood cultures 'S) to test S. aureusinections

o +reatment1 'mpiric A:B or S. aureusor Streptococcusand adjust as necessary or defniti/e

A:B therapy usually G-M eeks .8#$ olloed by oral or M-H ks hronic osteom#elitis ma# re:"ire fre:"ent interval of long5term ,2 as long as possible i you can2o Protect eight bearing

Trochanteric )"rsitis ,linical points

o Selling o bursa around trochanter$ may be due to repetiti/e microtrauma caused by dynamic use o themuscles that insert on the greater trochanter

o .n?ammation or irritation o the bursae surrounding the hip may lead to symptoms2 Sx 5 +enderness to palpation o/er the tip o the lateral or posterior aspects o the greater trochanter Dx 5 !). ill sho increased signal in bursa due to in?ammation on +J se6uence +x

o (onoperati/e (SA.DS$ stretching$ P+ including modalities$ corticosteroid injections

.ndications 5 frst line treatment is alays conser/ati/eo Operati/e

open /s arthroscopic trochanteric bursectomy

indications 5 is done only ater conser/ati/e measures ail *ip dislocation

o JKF are posterior.

o +ypical position5 internally rotated# .) 3 ?exed2 nee /s dashboard and alls2 )elocate ASAP to a/oid A8(2Post column x common2 Procedural sedation re6uired2

*ipfract"re intertrochanteric and femoral neck3o (eck x-old ladieso Intertrochanteric fxCmost common

o Subtrochanteric x5 high orces !8,o )epair can be a 6uick J- scres i (O+ displaced neck$ or re6uire O).F i displaced or more serious2 . needed

,+ or !).better#o ,omorbidities re6uire admission to internal medicine doc or elderly pts 0neck xo ,omplications

.nection D8+ Pulmonary embolism


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o Dx tests1 ,+ or !). !). better# 0napping hip

o Snapping that occurs as the iliotibial band subluxes o/er the greater trochanter or the iliopsoas tendonsubluxates o/er the pectineal eminence o the pel/is2 !ost common in omen$ especially omen athletes

o Sx Occurs ith ambulation or rotation o the hip2 Some may ha/e pain at the trochanteric bursa2 Pain hen

mo/ing rom a ?exed to an extended position2o 'xam

"a/e patient stand$ adduct$ and rotate the hip2 +he snap is palpated o/er the lateral hip as the iliotibialband subluxates o/er the trochanter

o . suspect intraarticular problem2 do Bray Bray is usually normal2 !). arthrogram i you suspect a labral tear

o +B Acti/ity precautions2 Phys therapy2 (SA.DS2 Steroid injection2

/em"r fxo "igh orces !O.2 ,ompartment syndrome is rare2 !idshat is most common2

+elvic /ract"reso Stable

+x1 typically heal ith resto 7nstable

:lood loss is big issue1


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A subchondral racture Tcrescent signU# may be identifed on the rog lateral2 :one scans and !).s are o little /alue

o 4abs ,ommonly perormed in children ho present ith a limp$ including a ,:, ith a di>erential$ 'S)$ and

,)P2 Additional studies such as 4yme titer$ )"$ antistreptolysin O titer$ and A(A

o +reatment ,hildren ith bone age YQ y and minor in/ol/ement do not need treatment :racing or surgery is recommended or older children and those ith more ad/anced disease Poor prognostic signs are age ZH y$ abduction Y- ness#$ CQEI o head in/ol/ements$ and

subluxation or lateral calcifcation +reatment has no e>ect on outcome i patient has a chronologic age ZH y at onset o the disease

0lipped capital femoral epiph#sis 0/-3o 'tiology

'tiology may in/ol/e se/eral actors2

.diopathic

"ypothyroidism

"ypopituitarism Progressi/e displacement o the upper portion o the emur relati/e to the capital emoral epiphysis2 %eakening o epiphyseal plate o the emur resulting in displacement o emoral head2

o 'ssentials +he condition most commonly occurs in adolescent boys Age


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LN--

Otto=a Lnee R"le- acute pain0injury nee Bray indications Age C05 QQ .solated patella tenderness +enderness at head o fbula .nability to ?ex knee ;E degrees .nability to bear eight G steps# immediately ater injury and in emergency department

Besions of the menisc"s ,licking and locking2 !ay ha/e e>usion acutely2 'xam C !). or lateral meniscus2 Apley@s grind test2 !c!urray@s

test2 Arthroscopic repair possible2 Discoid menisc"s

o Abnormal de/ o the meniscus leads to hypertrophic and discoid shaped meniscus2o AA popping knee syndromeo ,lasses

+ype usion 4oss o ull extension or loss o ?exion Positi/e !c!urrayWs test or positi/e Apley grind test

o Dx AP and lateral and axial patelloemoral knee x-rays to rule out racture or patella subluxation !). to determine i there is a torn meniscus

o +x .n the case o a degenerati/e tear initial treatment should be rest$ ice$ compression$ and ele/ation ).,'# (on-narcotic oral analgesics to reduce initial pain Degenerati/e tears that do not respond to conser/ati/e treatment should be considered or arthroscopy2 Patients ill re6uire physical therapy to restore motion$ strength$ and stretching2

o ,omplications


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Older patients ith degenerati/e tears may fnd that their symptoms become recurrent and that the onlydefniti/e treatment ill be arthroscopic e/aluation and treatment2

Osteoarthritis may be a late complication o subtotal or partial menisectomy2

+se"dogo"t ,alcium pyrophosphate dihydrate crystals2 mimics gout2 :ig crystals2 )homboid2 Sx

o Acute onset joint tenderness$ arm red joint2 knees and rists common P'

o red$ monoarticular arthritis2 tender .maging

o may see calcifcation o fbrocartilage structures +x

o A,7+' nonoperati/e2 (SA.D2 Splints or comorto ,")O(., nonoperati/e2 intraarticular yttrium-;E injections2 ,olchicine E2Mmg PO bid or recurrent cases#2

prophylactic colchicine can help to pre/ent recurrence

2aker c#st (ormal anatomic structures that represent a bursal sac beteen the semimembranous and medial head o the

gastroc !ay inc in si=e in the presence o meniscal tears or degenerati/e arthritis2 Sx

o ullness and mild paino

ruptured cyst may cause pain and selling in the cal rom ?uid leakage Dxo Found on !). or 7S

+xo (one i asymptomatico ,an aspirate or inject ith cortisoneo !ay recuro 9enerally resol/es spontaneously i intra-articular pathology assessedo )arely re6uires surgical excision

,B Tear Defnition5 An A,4 tear results most oten rom a rotational orce or hyperextension placed on the knee that

exceeds the strength o the ligament2 "appens in acti/e$ young adults2 ,lin "x

o Sudden onset o pain olloing a tisting or hyperextension injury to the knee2o usiono 'arly )O! exerciseso Surgery 5 Defniti/e treatment o an A,4 tear is arthroscopically assisted surgical reconstruction o the A,4$

using autograt or allograt2o Folloing surgery use o knee immobili=er$ then A,4 brace and P+2

,omplicationso 7ntreated$ and i instability and buckling occurs$ the patient risks su>ering a second and more de/astating

knee injury creating a multi-ligamentous unstable knee2Prognosiso 7ntreated and ith continuing instability$ patients also risk de/eloping traumatic arthritis o the knee2o 7se o A,4 brace is important in the post-operati/e phase until ade6uate strengthening has occurred2


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Prognosiso 9ood i treated ade6uately

Medial collateral ligament tear !O.

o .njury to the knee$ usually the result o a /algus stress$ hich produces a orce great enough to tear the medialcollateral ligament !,4#

o +he mechanism o injury to produce an !,4 tear or strain is generally a /algus abduction# orce ithout arotational component2

o ,an occur ith A,4 tear

,lin hxo Able to ambulate ater injury and may return to play or the rest o acti/ity2o Some locali=ed sellingo 'cchymosiso 4ocking$ popping$ or rank instability usually does not occur ith this injury

P'o Selling3 ecchymosiso palpate !,4 or tenderness best done ith the leg in the fgure G positiono 9rade tears open Cected knee and grade J tears open CQmm

Dxo AP and lateral x-rays to rule out other ractures and occasionally a small a/ulsion racture rom the origin o

the !,4 on the distal emur +x

o .solated !,4 tear treated conser/ati/elyo 9rade . strains resol/e spontaneously in a e eeksLrest$ ice$ compression$ ele/ation ).,'#Lolloed by

crutches to protect the knee2o 9rade .. tears re6uire use o a hinged brace until a gradual return to ull eight bearing is tolerated2o 9rade ... tears re6uire the use o a hinged brace ith a gradual return to ull eight bearing o/er a period o G

to M eeks2o 9rade ... injuries ill need to G months o protected bracing beore a return to unrestricted acti/ities2o Physical therapy re6uires an early range o motion acti/ities bicycling# and 6uadriceps and hamstring

strengthening2 complications

o Patients should be ad/ised as to the importance o physical therapy post-injury$ particularly i they plan toreturn to high-demand acti/ities2 prognosis

o .t is important to ully e/aluate patient and a/oid missing associated diagnoses A,4 tear$ meniscal tear#2

Bateral collateral ligament sprains !O.

o Force that pushes the knee sideays2 Oten contact injuries2o (ot as common as medial injuries2 A sprain occurs hen a joint is o/erstretched2

o First degree sprain - is a tear o only a e fbers o the ligament2

o Second degree sprain - is a tear o part o a ligament$ rom a third to almost all its fbers2

o +hird degree sprain - is a complete tear o the ligament2 P'

o Pain2 selling$ bruising2 decreased ability to mo/e the limb2 Dx

o !ade by P'2 Bray may be used to make sure other ractures are not present2 . a tear in the ligament issuspected$ then an !).or arthroscopy is obtained2 !). is usually ordered ater selling has subsided and canreadily identiy the presence o a ligament injury

+xo ).,'2 +he joint should be exercised airly soon2o (SA.DS may helpo A/oid eight bearing at frst then increase it gradually2

complicationso Prolonged immobili=ation delays healing o a sprain2 .t leads to muscle atrophy and a sti> joint2

prognosiso Prognosis is good

+osterior cr"ciate ligament tearso !O.

Direct blo to proximal tibia ith ?exed knee dashboard injury# (oncontact hyper?exion ith plantar-?exed oot

o ,lin hx dashboard injury2 hyper?exion athletic injury2
http://en.wikipedia.org/wiki/Magnetic_resonance_imaginghttp://en.wikipedia.org/wiki/Magnetic_resonance_imaging


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o P' Posterior draer test2

o Dx )adiographs

AP and lateral

kneeling stress radiographs o knee !). ,lassifcation based on posterior subluxation o tibia relati/e to emoral condyles ith knee in ;E\ ?exion#

9rade .


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hondromalacia patella Anterior knee pain due to sotening and degeneration o the articular cartilage o the patella may ha/e knee e>usion$ tenderness on the undersurace o the patellar crepitation2 Plain xray o the knee2 most helpul /ies are standing AP$ lateral$ and merchant or sunrise /ies2 +B

o conser/ati/eo muscle strengthening acti/itieso occasionally patella taping helpul

patella bracing helpul injection helpul

symptoms may be reracted in therapy$ especially in the young$ acti/e patient

Rec"rring patellar s")l"xation9 patellar insta)ilit# !O.

o +he kneecap slides up and don a groo/e on the end o the thigh bone as the knee bends2o patients ho experience an unstable kneecap ha/e a kneecap that does not slide centrally ithin its groo/eo .nstability o the patelloemoral joint co/ers a range o pathologic conditions o the knee$ ranging rom

malalignment o the patella and its relation to the distal emur to recurrent subluxation and dislocation o thepatella2

,lin hxo ,auses

%ider pel/is A shallo groo/e or the kneecap Abnormalities in gait

o

Dislocation or subluxation results in se/ere knee painR oten patients ill report hearing or eeling a TpopU andill see a deormity o the patella ith dislocation2o %ith a rank dislocation$ the patient maintains the knee in a ?exed position2o +he patella oten reduces spontaneously ith some degree o relie2o !arked selling o the knee

P'o . the patella has not spontaneously reduced$ there ill be a lateral deormity o the knee2o !arked apprehension signs ith any attempts by the examiner to mo/e the patella laterally2o )educed range o motion in extension and ?exion due to paino +enderness along medial patellar border i the medial retinaculum as torn

Dxo AP$ lateral and axial patelloemoral x-ray /ies are neededo %ith malalignment$ there ill be chronic lateral tilt o the patella2o Axial computeri=ed tomography ,+# may better demonstrate the relationship o the patella$ patelloemoral

joint$ and the trochlear2 +xo Protecti/e compressi/e dressing ith the a knee immobili=er maintaining the knee in extensiono . the e>usion is si=eable$ consider aspiration2o Oral analgesics$ rest$ iceo '/entually physical therapy can begin and ad/ance sloly$ emphasi=ing gentle 6uadriceps strengthening$

patellar taping techni6ues2o Orthopedic reerralo . medical treatment ails$ surgery to address extensor mechanism realignment

complicationso ,hronic instability can lead to patelloemoral arthrosis

,c"te dislocation of the patella !inor issue2 it@ll pop back in2 teenagers2 7sually relocates easily extend#2 "appens in people ith XlaxX joints

Dislocation of Lnee !ajor2 8ascular injuries are common2 Some ,+ angiogram,+A# all dislocated knees to )0O popliteal injury2 !ost

relocate spontaneously2 :i-cruciate ligamentous instability means a dislocated knee occurred2

Open knee (eeds to go to O) and get ashed out2 !ethylene blue arthrogram or Saline arthrogram


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o exacerbated by kneeling P'

o 'nlarged tibial tubercleo tenderness o/er tibial tubercleo Pain on resisted knee extension

)adiographso lateral radiograph o the kneeo .rregularity and ragmentation o the tibial tubercle2

!).o (ot essential or diagnosis

o diagnosis can be made based on history$ presence o tender selling and radiographs aloneo Sot tissue sellingo thickening and edema o inerior patellar tendono ragmentation and irregularity o ossifcation center

+xo (onoperati/e

(SA.DS$ rest$ ice$ acti/ity modifcation$ strapping0slee/es to decrease tension on the apophysitis and6uadriceps stretching .ndications 5 frst line o treatment

Outcomes 5 ;EI o patients ha/e complete resolution cast immobili=ation x M eeks

indications 5 se/ere symptoms not responding to simple conser/ati/e management abo/eo Operati/e

ossicle excision

indications 5 reractory cases


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auto or allograt tissue may be needed to secure 6uadriceps tendon to patella

Osteochondritis dissecans Pathologic lesion a>ecting articular cartilage and subchondral bone ith /ariable clinical patterns2 !ost common joint is knee u/enile

age


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o ,hip xo +orn piece o cartilage

Sxo locking o the knee that comes and goeso pain and selling o the knee that comes and goeso eel the loose body by touching the knee

.maging 5 Bray$ ,+$ or !). to fnd loose body +B 5 !ay include surgery or remo/al and repair o the kneecap i causing symptoms

Osteonecrosis

caused by reduced blood ?o to the bones and joints2 :one starts to die and may break don Sx 5 oint pain that becomes more se/ere2 +x

o (SA.DSo non-eight bearingo )O! exerciseso 'lectrical stimulationo Surgery

,ore decompression surgery-loer press inside bone to inc blood ?o Osteotomy- reshapes the bone to reduce the stress on the damaged joint2 :one grat2 takes health bone rom one body part to the bad part2 +otal joint replacement2 replaces the joint ith a manmade one2

2"rsitis ,hronic riction or trauma leads to in?ammation or inection and thickening o the bursa J most common at the knee

o Pes anserine bursitis !edial knee here the conjoined hamstring tendons insert to the tibia2 Seen in OA and obesity Sx 5 Pain ith rest and orse at night2 Antalgic gait P'

+ender on palpation o medial tibial ?are

Bray e/al or a stress x +x 5 "eat0ice$ nsaids$ injection$ hamstring stretching

o Septic prepatellar bursitis "ousemaidWs knee2 Direct trauma causing an abrasion common as ell$ ,ommon pathogen is S aureus

Sx Sudden se/ere pain$ sti>ness$ armth$ e>usion o bursa

P'

'rythema$ edema$ and dome shaped e>usion2

:e sure to di>erentiate a septic joint intra-articular fndings# From a septic bursa

Dxo Bray normal except or anterior sot tissue edema2o ,:, and Di>o ,)Po Aspirate bursa or ,:,$ gram stain$ ,NS

+xo .8 abx2 .ND2o Ance Jgrams unless culture demonstrates other organism

Tendonitis !O.

o Sometimes the tendons become in?amed or a /ariety o reasons$ and the action o pulling the musclebecomes irritating

,lin hxo !ostly an o/eruse injury2

P'o +endonitis is almost alays diagnosed on physical examination2 Findings consistent ith tendonitis include1

+enderness directly o/er the tendon

Pain ith mo/ement o muscles and tendons

Selling o the tendon Dx


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o Studies such as x-rays and !).s are not usually needed to make the diagnosis o tendonitis2 %hile they are notneeded or diagnosis o tendonitis$ x-rays may be perormed to ensure there is no other problem$ such as aracture$ that could be causing the symptoms o pain and selling2 B-rays may sho e/idence o sellingaround the tendon2

+xo )est and protection o the area2o A/oid aggra/ating mo/ements2o (SA.DS may helpo . symptoms are present$ steroid injection may help2o Achilles tendon is not usually injected due to risk o rupture2

o Physical therapy complicationso +endonitis due to underlying conditions such as arthritis and gout are more diKcult to treat and recur more

re6uently2 +he best management in these situations is to do your best to a/oid ?are-ups o gouty attacks orarthritic episodes$ and to a/oid acti/ities hich you ha/e learned cause tendonitis2

/ract"res of the knee !O.

o Fractures about the knee are classifed as supracondylar or condylarR the latter in/ol/ing either the medial orlateral condyle2 Fractures o the knee in/ol/ing the tibia are classifed as tibial plateau ractures2

o .n younger patients these ractures result rom a high energy trauma and are oten associated ith otherinjuries$ hile in older patients they can result rom relati/ely lo energy trauma in the presence oosteoporosis2

,lin hxo .mmediate onset o pain and selling ith diKculty eight bearing

P'o Selling is usually signifcant due to the bleeding that occurs ithin the joint2o .nspect the skin or skin integrity and the possibility o an open racture2o '/aluate or concomitant injuries specifcally to the superfcial or deep peroneal ner/es$ posterior tibial ner/e$

and check distal pulses2 Dx

o AP and lateral x-rays o the knee and$ i surgery is planned$ obli6ue /ies Book for air in !oint indicates O+-N LN--

o . distal pulses are compromised$ obtain an ultrasoundo Saline /s2 !ethylene :lue arthrogram to assess OP'( /s ,4OS'D

+xo displaced or minimally displaced ractures re6uireo Open ractures$ intraarticular ractures$ /ascular injuries$ or compartment syndrome all re6uire immediate

surgical inter/ention2o Patients ith large hemarthroses can obtain signifcant relie ith aspiration o the joint under sterile

techni6ue2 ,omplications 5 .ntraarticular ractures$ e/en in the best o hands$ increase the risk o traumatic arthritis in the

uture2

Ti)ial platea" "igh orces2 Auto /s pedestrian is classic2 :umper into knee2 9et plateau /ies or obli6ues2 Once knon$ ,+ is

becoming standard to describe x preop2o +x1 ORI/ is virt"all# al=a#s needed

%orry about popliteal artery

+atella tendonitis O/eruse or o/erload o the extensor mechanism at the inrapatella tendon ,ommon in athletes umpers knee# and in obesity2 non as Osgood-SchlatterWs disease hen present at the tibial tubercle physis in the groing adolescent SB

o Ant knee pain2 pain hen sitting$ s6uatting$ or kneeling2 pain ith climbing stairs2 P'

o Point tenderness at patella tendon2 Pain on knee extension against resistance Bray should be normal2 +B 5 )est2 (SA.DS2 P+ 7ltrasound Phonophoresis helpul# DO (O+ .(',+2 ,ho-Pat Strap

Ti)ial eminence fract"re !O.

o A racture o the bony attachment o the A,4 on the tibia 'pidemiology

o rare injurieso most common in ages H-


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traumatico rapid deceleration or hyperextension o the kneeo same mechanism that ould cause A,4 tear in adult

,lin hx 5 +rauma P'

o .mmediate knee e>usiono 4imited )O! secondary to paino Positi/e anterior draer2

Dxo )adiographs 5 recommended /ies 5 standard knee radiographs

o ,+ 5 useul or pre-operati/e planningo !). 5 better at determining associated ligamentous0meniscal damage than ,+ or radiographso ,lasses

+ype < nondisplaced type J minimally displaced ith intact posterior hinge type completely displaced

+xo (onoperati/e

closed reduction$ e/acuation o hemarthrosis$ immobili=ation in E-JE degrees o extension

indications 5 non-displaced type . and reducible type .. ractureso Operati/e

O).F /s2 all-arthroscopic fxation

.ndications 5 +ype ... or +ype .. ractures that can@t be reduced complications

o Arthrofbrosis more common ith surgical reconstruction#o 9roth arresto A,4 laxity

incidence


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considered an orthopedic emergency splint knee in JE-E degrees o ?exion confrm reduction is held ith repeat radiographs in brace0splint /ascular consult indicated i

i arterial injury confrmed by arterial duplex ultrasound or ,+ angiography

pulses are absent or diminished olloing reduction (onoperati/e indications 5 limited and most cases re6uire surgical stabili=ation Operati/e 5 emergent surgical inter/ention

indications

/ascular injury repair takes precedence#

open x and open dislocation irreducible dislocation

compartment syndrome techni6ue 5 /ascular inter/ention

perorm external fxation frst

excision o damged segment and repair ith re/erse saphenous /ein grat

alays perorm asciotomies ater /ascular repair delayed ligamentous reconstruction0repair

o indications generally instability ill re6uire some kind o ligamentous repair or fxation patients can be placed in a knee immobili=er or M eeks or initial stabili=ation

impro/ed outcomes ith early treatment ithin eeks#o techni6ue

P4, 5 recommend early reconstitution

P,4 5 reconstruct prior to A,4 reconstruction Postoperati/e 5 recommend early mobili=ation and unctional bracing

o complications Sti>ness arthrofbrosis#

is most common complication HI#

more common ith delayed mobili=ation 4axity and instability [I# Peroneal ner/e injury JQI#

most common in posterolateral dislocations

poor results ith acute$ subacute$ and delayed C months# ner/e exploration

neurolysis and tendon transers are the mainstay o treatment 8ascular compromise

in addition to /essel damage$ claudication$ skin changes$ and muscle atrophy can occuro prognosis

complications re6uent and rarely does knee return to pre-injury state


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+ediatric Orthopedics

Dra the Salter classifcation o epiphyseal racturesand state the prognostic signifcanceo the classifcationsecting the groth process

# 0alter *arris classiHcation MN-UMONI5 S A 4 + )#i# . V S 5 0lip separated or straight across32 Fracture o the cartilage o the physis groth plate#2


24/54

i2 !inor 5 spinal bracing and castingii2 Se/ere 5 re6uire surgery to pre/ent long term problems ith the spine$ lungs$ or other

organs2iii2 Surgery options include groing spine instrumentation such as groing rods or the 8ertical

'xpandable Prosthetic +itanium )ib 8'P+)# in younger patients or spinal usion in olderteenagers and young adults2

en the back and tighten the hamstringmuscles$ resulting in changes to posture and gait2

iii2 !ay ha/e loer leg paini/2 . the slippage is signifcant$ it may begin to compress the ner/es and narro the spinal

canal


25/54

b2d2 .n se/ere cases$ an obli6ue groo/e is noted on the medial side o the oote2 Physical exam

a2 !easure hip rotationb2 !easure rotational status o loer leg and oot

2 +reatmenta2 9enerally no treatment is needed as the condition re6uently resol/es by


26/54


27/54

*and and Wrista2 ,arpal tunnel syndrome ,+S#

1. !ost common mononeuropathy. ,ompression o median ner/e in the carpal tunnel space on palmar aspect o rist bounded by

scaphoid$ trape=ium$ capitate$ hook o hamate$ pisiorm$ and trans/erse carpal ligament#%. 7S7A44& D7' +O1 o/eruse phenomena and trauma2&. ,ommon in middle aged omen'. Diagnosis /ia clinical presentation mostly2. 0peciHc disease association7 h#poth#roidism$ pregnanc#$ and dia)etes

ii. Symptoms1

1. (umbness in the median ner/e distributionR pain aakens patient rom sleepR rist-?exedacti/ities are uncomortable and elicit symptoms. +inel sign tapping /olar aspect o rist#$ Phalen rist ?exion test negati/e ater < min#$ eak

opposition$ or thenar atrophy may be present%. !ost sensiti/e test is carpal compression direct compression o/er carpal tunnel or ME s#R sensory

exam is /ery helpuliii. .maging

1. Obtain radiographs$ including a carpal tunnel /ie$ to r0o bony causes o ,+S. '!90(,S can help di>erentiate rom other entities but fndings are oten normal in early ,+S%. Atrophy o thenar muscles is a sign o ad/anced disease

iv. +reatment1. Administer (SA.Ds2 :egins ith splinting in slight extension and e/aluation o causes other than

idiopathicR . conser/ati/e treatment ails$ consider steroid injections in the carpal tunnel can helpreduce symptoms or a period o time

. %ork-related ,+S may beneft rom ergonomic aids2

%. ,+S o pregnancy usually resol/e ater deli/ery2&. Surgical treatment is reser/ed or fxed sensory loss$ thenar eakness$ or intolerable symptoms2'. Surgical treatment is indicated hen conser/ati/e therapy is unsuccessulR the trans/erse carpal

ligament can be di/ided by open surgery or by endoscopic surgeryR success rates are highv. ,O!P4.,A+.O(S 5 Permanent loss o sensation$ hand strength$ and fne motor skills2

b2 9anglion cysto the risti. !ost common cause o sot tissue mass on hand and rist U0U,BB NONT-ND-R3

1. ,ysts may de/elop at joints$ tendons$ or ner/es2. %rist joint cysts arise most commonly dorsally rom the region o the scapholunate ligament Fig2

Qect median ner/e andinduce carpel tunnel syndrome2

'. .n e/aluating a /olar radial rist cyst$ it is important to perorm an Allen test to determine patencyo the radial artery2

ii. ,ysts contain thick$ gelatinous material2iii. +he cysts most commonly occur in the second to ourth decades o lie2iv. %omen are three times more likely than men to de/elop a ganglion cyst2v. !ost ganglion rist cysts are asymp and are oten present or months to years prior to e/aluation2

vi. +reatment1. Some spontaneously resol/e. ,spiration and in!ection =ith cortisone"igh rates o reoccurrences#%. Rec"rrences can )e removed s"rgicall#must remo/e the stalk o cyst#

a2 Dorsal ganglion rist ill not a>ect neuro/ascular structuresb2 8olar radial rist cyst is adjacent to radial artery and /enae comitantes caution#

. 4ist the physical exam fnding distinctions beteen osteoarthritisand rheumatoid arthritiso the hand

a2 Osteoarthritisi. A common$ chronic$ nonin?ammatory arthritis o the syno/ial joints e2g2$ D.P joints#2

1. ,haracteri=ed by deterioration o the articular cartilage and osteophyte and subchondralbone ormation at the joint suraces2 )isk actors include a 3 amily history$ o)esit#$ and ahistor# of !oint tra"ma.

ii. ".S+O)&0P'1. Presents ith crepitusR ] )O!R and initially pain that orsens ith acti/ity and eight

bearing but impro/es ith rest2 !orning sti>ness lasts or Y E minutes2 Sti>ness is alsoexperienced ater periods o rest TgellingU#2

iii. D.A9(OS.S1. )adiographs sho joint space narroing$ osteophytes$ subchondral sclerosis$ and

subchondral bone cysts2 )adiograph se/erity does not correlate 0 symptomatology2. Syno/ial ?uid shos stra-colored ?uid$ normal /iscosity$ and a %:, count Y JEEE

cells0^42


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iv. +)'A+!'(+1. Physical therapy$ eight reduction$ (SA.Ds2 .ntra-articular corticosteroid injections may

pro/ide temporary relie2 ,onsider joint replacement e2g2$ total hip0knee arthroplasty# inad/anced cases2

b2 )heumatoid arthritisi. Symmetric joint destructionii. P.P '(4A)9'!'(+S bouchard#

1. DI+ "s"all# spared he)erden nodes C osteoarthritis 3iii. (ote the boutonni_re deormities o the digits$ ulnar de/iation o the fngers$ !,P joint

hypertrophy$ and se/ere in/ol/ement o the P.P joints2iv. 'xtra-articular maniestations$ including subcutaneous nodules$ pulmonary nodules$ /asculitis$

pericarditis$ or episcleritis$ may be detected2v. Physical fndings

1. Symmetrical selling in the !,P joints ,an in/ol/e the P.P and the thumb later#. !orning sti>ness lasting more than < hour%. ,hronic in?ammation leads to deormity o ulnar drit$ san neck$ and boutonniere

a2 San neck 5 P.P hyper extension D.P hyper ?ex#b2 7lnar drit 5 fngers point to pink slanted#c2 :outonniere 5 P.P hyper ?ex D.P hyper extend#

&. 7sually associated ith carpal tunnel syndrome'. B-rays sho early notching in the periarticular area. !). sensiti/e or bone erosions

vi. 4abs 5 )heumatoid actors and antibodies to citrulline-containing peptides ,,P# are helpul ordiagnosis$ hile acute phase reactants are helpul in monitoring disease acti/ity

vii. +reatment 5 D!A)DS

%. State the physical exam fndings and treatment o Dupuytren contractureand De *uer/ain tenosyno/itisa2 Dupuytren contracture

1. Progressi/e fbrosis nodular thickening# on the ascia o the palmar surace o the handRa2 9enetic association ith Peyronie disease penile fbrosis# or 4edderhose disease

plantar oot fbromatosis#b2 Alcohol$ smoking$ and diabetes

. !ore common in men$ ith usual age o onset GEVME yR predisposition in patients onorthern 'uropean ancestry and occasionally Asians

%. ,auses gradual contracture o the palmar ascia$ resulting in !,P# and P.P# jointcontracturesR usually the little fnger is orst

ii. Symptoms o fngers# TcatchingU in pockets$ cosmetic complaints$ shaking hands$ andoccasionally$ ith se/ere cases o contracture$ hygiene o the fnger creases

iii. +reatment1. (onoperati/e treatment is eKcacious in milder orms o the disease hen joint ?exion

contractures are small. Surgical treatment is indicated to remo/e the ascia asciectomy# causing the

contracturesR joint contracture o E degrees at the !,P or any contracture at the P.P jointis the indication or surgery

%. .n se/ere$ neglected cases or cases ith neuro/ascular compromise or extreme sti>ness$amputation o the little fnger may be necessary

&. Surgery is risky because neuro/ascular structures are intimately adherent to the nodularascia in Dupuytren contractures

'. 'arly surgery pre/ents se/ere contractures but has high rate o recurrence o d=b2 De*uer/ainWs tenosyno/itis

1. .s a stenosing tenosyno/itis occurs at the radial styloid and in/ol/es the abductor pollicislongus and extensor pollicis bre/is

. .n?ammation is under the retinaculum o the frst extensor compartment%. !ore common in emales CE yo and diabetics

&. ,an occur rom injury$ in?ammatory disease 5 rheumatoid arthritis$ degenerati/e jointdisease$ or rist racture2'. De *uer/ain tenosyno/itis may be accompanied by a symptomatic ganglion$ or triggering

o the tendons in the compartment$ or both2ii. Physical exam

1. Patient has a history o pain at the radial side o the rist ith acti/ities in hich thethumb is abducted or the rist is ulnarly de/iated2

. Pain and tenderness occur at the rist and base o the thumb and may radiate upshoulders2

%. Selling and thickening o the tendon sheath upon examination2&. Palpation elicits pain at the site o the retinaculum at the radial styloid#

iii. Signs1. /inkelstein test1 thumb is put in the palm and enclosed by the fngersR the rist is

abruptly de/iated ulnarlyR positi/e test results in pain at the radial side o the rist


29/54

. 3 "itch hikers sign abduct thumb radially against resistance#a2 3 :runelli test 5 perormed by ha/ing the patient acti/ely radially abduct the

thumb ith the rist in radial de/iation%. box# is tender upon palpation

iv. +reatment1. Splinting does not cure the problem but pro/ides symptomatic relie. Steroid injection into the frst extensor compartment is successul in most patients$ but as

many as JQI need a second injection to get relie$ probably because the J tendons ha/eseparate compartments and the abductor has /ariable numbers o accessory tendon slips

%. Surgical release o the retinaculum is indicated or patients ho do not respond toconser/ati/e therapy

&. Defne trigger fngerand einbock diseaseand discuss their treatmentsa2 +rigger fnger

i. Stenosing ?exor tenosyno/itis results rom locali=ed tenosyno/itis o the superfcial and deep ?exotendons adjacent to the A< pulley at the metacarpal head2 +his in?ammation causes hypertrophyo the A< pulley$ hich leads to discrepancy beteen the tendon and the tendon sheath

ii. +ypes1. Di>use 5 ith thickening o the entire ?exor tenosyno/ium more commonly seen in

rheumatoid arthritis#. (odule 5 ith thickening o the tendon on the distal edge o the A< pulley

iii. ,ongenital at birth 5 children# /s2 ac6uired1. Ac6uired 5 adults. !ore common in omen and C older than GE yo2

iv. .t can a>ect any digit but most commonly a>ects the ring fnger$ thumb$ and long fnger2v. .t is associated ith medical conditions such as diabetes mellitus$ hypothyroidism$ gout$ renal

disease$ and rheumatoid arthritis2vi. Patients ho de/elop trigger digits are more likely to be a>ected by carpal tunnel syndrome and

de *uer/ain stenosing tenosyno/itis2vii. S0S 3 Physical exam

1. On examination$ can eel tender nodule trigger on ?exion and extension o the fnger at theA< pulley

. Patients typically present ith a tender nodule located on the palm at the metacarpal headand the inability to smoothly extend or ?ex the digit2 +heir complaints are sometimes/ague$ consisting o aching in the palm and morning sti>ness o one or more digits2 As the?exor tenosyno/itis becomes more se/ere$ patients ha/e increased pain at the nodule andincreased triggering that occurs during ?exion or pre/ents them rom ully extending thefnger2

viii. +reatment depends on se/erity1. 'arly stages o tenosyno/itis$ (SA.Ds 3 massage 3 heat 3 splint. !oderate0reractory 5 ,orticosteroid injection into tendon sheath /ery successul#

a2 %ater-soluble steroids such as betamethasone sodium phosphate and acetatesuspension are preerred because they do not precipitate$ lea/ing a residue2

b2 ,omplications such as depigmentation$ at necrosis$ ?are reaction$ andhyperglycemia should be discussed ith patient2 .njections are less likely to besuccessul in patients ith triggering or CM months$ di>use tenosyno/itis$ anddiabetes mellitus2

%. Surgical release o tendon pulley or ailures o injectionb2 einbock disease

i. ienb`ck@s disease is a condition here the blood supply to one o the small bones in the rist$ thelunate$ is interrupted2 )esulting in osteonecrosis2

ii. Damage to the lunate causes a painul$ sti> rist and$ o/er time$ can lead to arthritis2iii. ,ause is unknon2 !ay be as a result o pre/ious rist x or injury that disrupts blood ?o2iv. ,ommon


30/54

&. Stage G 5 . the condition progresses to Stage G$ the suraces o the bones surrounding thelunate also deteriorate$ and the rist may become arthritic2

vii. +he most common symptoms o ienb`ck@s disease include11. A painul and sometimes sollen rist2. Pain that radiates to the orearm$ rist sti>ness$ selling or tenderness o/er the lunate$

and decreased grip strength2%. 4imited )O! in the a>ected rist sti>ness#R Pain or diKculty in turning the hand upard&. +enderness directly o/er the bone on the top o the hand at about the middle o the rist#

viii. +reatment1. 'arly stages 5 ibuproen 3 J- eeks o splinting or casting to relie/e pressure rom lunate. . cause is short ulna$ surgical shortening o radius2%. Surgical stage < 3 J 5 re/asculari=ation&. oint le/eling ith bone grats to reduce orm on lunate and pre/ent progression'. Proximal ro carpectomy2 . the lunate is se/erely collapsed or broken into pieces$ it can be

remo/ed2 .n this procedure$ the to bones on either side o the lunate are also remo/ed2 +orelie/e pain and maintain partial rist motion2

. Fusion o nearby rist bones ith plate$ scres$ and pins# to make one solid bone inse/ere arthritic rist2 )elie/es pain and retain some rist motion2 %rist motion iseliminated in a complete usion$ but orearm rotation is preser/ed2

'. Discuss the etiology$ physical fndings$ mechanism o injury$ and treatment or mallet fngerand boutonnieredeormityo ersey Finger

)upture o Flexor Digitorum Proundus tendon !O.1 orceul hyperextension S0S1 inability to acti/ely ?ex the D.P joint

+x1 aluminum splint in slight ?exiono !allet fnger

4oss o ull$ acti/e extension o the distal interphalangeal D.P# joint$ resulting in unopposed ?exordigitorum longus action to pull the distal phalanx into ?exion2 resulting in ull ?exion o D.P#

can be due to a/ulsion o the tendon ith or ithout a ragment o bone$ or rupture or laceration o thetendon inserting on the distal phalanx

+raumatic except or rheumatoid arthritis# Patient oten presents late$ eeks ater the injury )adiographs are necessary to determine i an intra-articular racture is present +reatment

.njuries are usually closed and can be treated ith continuous splinting o the D.P joint in ull extensionor H k

Articular ragments i small ie$ YI o the joint surace# can be ignored and treated as i ligamentinjuries

Single large racture ragments can be treated operati/ely to reduce the racture

oint is usually pinned in extension

,hronic mallet fnger can oten be successully treated ith splintingR i splinting is unsuccessul andthe amount o fnger ?exion is unacceptable$ fnger usion is an option

Surgical management is reser/ed or patients ho cannot ork ith a splint in place or those hoha/e large ragments or dislocated joints2

o :outonniere deormity P.P hyper?exion and D.P hyper extend secondary to central slip disruption on the middle phalanx

laceration$ closed rupture$ syno/itis o P.P joint#2

:asically locks the P.P joint in ?exion$ resulting in contracture Subluxated lateral bands and unopposed ?exor digitorum proundus are the main deorming orces ,ommonly seen )A !,P 3 P.P# and Osteoarthritis P.P 3 D.P# +reatment

+reat an acutely lacerated central slip ith direct repair and pin- ning o the joint in ull extension or VM k

+reat acute$ closed ruptures o the central slip by splinting the P.P joint in ull extension or M k

Delayed treatment1 prolonged splinting ith ,apener splint$ or oint ack splint /ersus serial castingRpatients ith delayed diagnosis may de/elop fxed ?exion contracture o P.P joint

o 9amekeeperWs +humb S0S1 eakness o pinch +x1 thumb spica cast /s surgical repair

. 4ist the etiology$ organisms$ physical fndings$ and +B or human bites$ paronychia$ and tendon sheath inxno human bites

oten rom fst striking toothR penetrates skin$ subcutaneous tissue$ extensor tendon$ and capsule ometacarpophalangeal !,P# joint

may lead to osteomyelitis i untreated


31/54

bites distal to rists are more at risk or malignant inections due to superfcial spaces ,onsider 'ikenella corrodens$ /iridans streptococci$ group A streptococci$ S aureus$ :acteroides$

Fusobacterium$ Actinomycetes$ spirochetes LanavalAs 0ign1 Flexor tendon sheath#

S0S1 se/ere pain on passi/e extension$ redness0pain along ?exor tendon

+x1 surgical .ND and Abx +reatment

.ncision and drainage arthrotomy i !,P in/ol/e- ment is suspectedR begin broad-spectrum .8antibiotics olloed by oral penicillin$ ampicillin$ amoxicillin-cla/ulanate$ and tetanus prophylaxis asindicated

+etanus re6uired (O+' 97'S+ 4',+7)'S +)'A+!'(+ OF ,"O.,'

Augmentin

. penicillin allergic$ :actrim04e/a6uin 3 clindamycino Paronychia

in?ammation o nail olds caused by nail cosmetic ser/ice or prolonged ater immersion inections can be acute or chronic

acute 5 staph aureus as cellulitis C leads to abscess ormation

chronic 5 candida associated ith nail biting# +reatment

+reatment or acute inection begins ith arm soaks and oral antibiotics

Staph 5 :actrim or nacillin

.ncision and drainage is re6uired ater an abscess orms Partial nail remo/al may be necessary to decompress the abscess

+reatment o chronic inection includes antimicrobial agents and maintenance o dry hands$ and mayre6uire nail remo/al M eeks antiungals

o +endon sheath inections Syno/ial inection o ?exor tendon sheath !ay or may not re6uire .ND$ monitor closely$ rest$ and anti)iotics

. State the mechanism o injury$ physical fndings$ radiographic fndings$ treatment and complications o theolloing fract"res1o Shat o the ulna racture

AA nightstick fract"redirect blo# Occurs more oten in males$ generally as a result o an altercation$ all$ contact sports$ or !8A

Presence o pain$ locali=ed selling$ and crepitus Fracture o the ulnar shat can be assoc2 0 dislocation o the radial head !onteggiaWs lesion# )adial or posterior interosseus ner/e injuries are common$ especially in the !onteggiaWs /ariant Displaced ulna ractures usually mean a disruption o the distal or proximal radioulnar joints$ i the radius is

not ractured2 +reatment

(ondisplaced ractures can be treated closed

Open ractures or those displaced CQEI o the diaphyseal diameter or angulated C


32/54

9alea==i Fx1 distal radio-ulnar joint injury 3 radius x+x1 O).F

!onteggia Fx1 ulnar x 3 radial head dislocation+x1 O).F

'ssex-4opresti Fx1 crush to radial head 0 D)7 dislx+x1 O).F

o ,olles racture

Sil/er ork deormity 5 Fracture o distal radius leading to dorsal angulation +x1 typically closed reduction$ may re6uire O).F

o +ri6uetral racture ;EI o FOOS" racture# Dorsal chip racture due to FOOS"

o Scaphoid racture :one most common ractured on the rist2 "B o a all on an outstretched hand2 :lood supply is rom radial artery rom lateral and distal branches2 Proximal pole o scaphoid has poor

blood supplyR untreated can lead or prone to nonunion or a/ascular necrosis2 ,omplications

.nclude nonunion o the racture or de/elopment o a/ascular necrosis2 .n a/ascular necrosis$radiography may re/eal a ground-glass appearance o the proximal pole or an increased bone density2

,linical presentation

< SB 5 pain o/er snu> box and has ecchymosis

Symptoms include pain and selling on the radial side o the rist2

.mage .nitially B)A&s are not diagnostic2 AP$ lateral$ and scaphoid /ies should be ordered2 )epeat xray J-

eeks :one scan$ !).$ or ,+ may be helpul or acute injury

Diagnose based on symptoms easily conused ith rist sprain# +reatment

For nondisplaced ractures$ long arm thumb spica cast ith the rist in neutral or M eeks2 . ater Meeks x-ray shos e/idence o healing$ replace long arm cast ith a short arm thumb spica cast orse/eral more eeks$ olloed by a brace2

. no e/idence o healing in ollo-up x-rays or idening o the racture line$ consider surgicalinter/ention2

Displaced ractures and ailed medical management$ re6uire inter/ention by a hand surgeon or urthertreatment2

o :ennetWs racture .ntra-articular Fracture at :ase o thumb .ntra-articular racture o the base o the frst metacarpal in hich the small /olar ragment remains

attached to the trape=ium and the thumb and frst metacarpal are displaced proximally and radially !etacarpal shat is displaced by the orces o the extrinsic thumb extensors and abductor pollicis longus

muscles2 +reatment

!ust be reduced re6uire immediate B-ray# and fxated ith percutaneous pins2

+humb splint spica# cast i closed racture or M eeks2

. reractory$ must perorm open reduction and internal fxation2o :oxer racture

See belo Qthmetacarpal neck racture

o !etacarpal racture

di/ided into ractures o metacarpal head$ neck$ shat metacarpal neck racture is most common Q thmetacarpal x 5 boxerWs racture#

treatment based on hich metacarpal is in/ol/ed and location o racture acceptable angulation /aries by location no degree o malrotation is acceptable

o Phalangeal racture Fractures o proximal and middle phalanges can be at the base$ neck$ shat$ or intra-articular2

Also be classifed by open or closed2 Pain and selling ith decreased range o acti/e motion$ and possibly deormity$ are reported ater a

history o trauma +enderness to palpationR pain ith passi/e motion Selling and ecchymosis may be present )adiographic exam is diagnosticR comparison /ies may be helpul i the physes are open


33/54

+reatment

Undisplaced fract"rescan be treated ith splinting$ either a gutter splint radial or ulnar$ dependingon the racture# or a short-arm cast ith an outrigger to protect the digitR splinting or


34/54

0+IN- ,ND +-BI0

Red Gags7,are should be taken to ensure that constitutional symptoms are not reported$ such as fever$ chills$ painthat =akes the patient from sleep$ =eight loss$ malaise$ and the likeR these arning signs can signiy moreominous conditions such as inection or malignancy2 )'*7.)' !).#

ervical 0pine ,er/ical disc syndrome

o "erniated disc TSame as in lumbarU occurs ater traumatic episodes2

!ost herniations occur beteen ,Q and +nessand in?exibility

Additional symptoms may consist o numbness$ tingling$ or e/en eakness in the neck$ arms$ orshoulders as a result o ner/es in the cer/ical area becoming irritated or pinched2

,er/ical degeneration can become so se/ere that surrounding osteophytes may encroach on the spinalcanal$ leading to spinal stenosis and myelopathy2 Symptoms o myelopathy include akard or stumbling gait$ diKculty ith fne motor skills in the

hands and arms$ and tingling or shock-type eelings don the torso or into the legs2 .maging

4ateral x-ray o the cer/ical spine2 B-ray re/eals loss o lordosis$ osteophyte ormation$ and a decreasein disc space2

!). can be utili=ed to determine hether there is ner/e root compression or cer/ical stenosis inpatients ho present ith neurologic symptoms2 (er/e root or spinal cord compression secondary to aherniated nucleus pulposus$ abscess$ or tumor can be easily identifed ith !).2

+reatment

Symptomatic 5 (SA.Ds and P+ or M eeks

i se/ere symptoms or in?ammation$ epidural steroid injections2

Spine surgery is perormed i a course o conser/ati/e treatment has ailed2 Surgery consists o discremo/al$ placement o an inter/ertebral bone grat$ and usion2 Plate fxation is generally used ormultiple le/els o in/ol/ement2 Patients are placed in a sot collar postoperati/ely or comort and aregenerally discharged the olloing day2

,er/ical strain


35/54

o Pearl +issue in?ammation as a result o hiplash2

,ommon mechanisms o cer/ical strain injury include rear-end automobile collisions$ sports traumae2g2$ ootball#$ and repetiti/e occupational injuries2 !uscular and ligamentous structures o thecer/ical spine are stretched beyond their physiologic capacity$ generating in?ammation ithin thelocal sot tissues2 Patients ith cer/ical strain may present ith a constellation o symptoms includingneck pain$ persistent sti>ness$ trape=ial pain$ back pain$ muscle spasm$ headache$ and limited rangeo motion2 +hese symptoms oten begin acutely$ hours ater the injury2

d0t hyperextension olloed by hyper?exion2 ,er/ical spine stability must frst be /erifed beore the diagnosis o cer/ical sprain can be made2 'xamine

appropriate ,-spine series$ including ?exion and extension /ies2o Symptoms1

Pain is the chie complaint and minor 5 sti>ness# 4ocal tendernessR decreased range o motionR headaches$ typically occipitalR blurred or double /ision Dysphagia$ hoarseness$ ja pain$ diKculty ith balance$ /ertigo Strain reers to muscle injuriesR sprain$ to ligamentous and capsular injuries

o .maging +hereore$ clinical decision guidelines or the judicious use o cer/ical radiography ha/e been de/eloped

based on history$ physical examination$ and simple tests2 +o decision-making tools ere de/elopedindependently1 the (ational 'mergency B-)adiography 7tili=ation Study ('B7S# 4o-)isk ,riteria (4,#and the ,anadian ,-Spine )ule ,,)#2

B ray i older than MQ yo$ paresthesia$ major rear in collision$ acute onset o pain ith midline cer/icaltenderness$ and unable to rotate neck GQ degrees2

o +reatment

.nitial therapy is rest ith sot collar immobili=ation and (SA.Ds2 'ncourage early progressi/e range omo/ement2

!any patients ha/e persistent symptoms2o Factors associated ith a poor prognosis include the presence o occipital headaches$ interscapular pain$

re/ersal o cer/ical lordosis$ and in/ol/ement in litigation or orkersW compensation claimsR omen ha/e aorse prognosis than men2

,er/ical subluxation and dislocationo !isalignment o /ertebral body and symptoms depend on se/erity

!inor symptoms 5 ner/e root impingement !ajor symptoms 5 spinal cord compression

o 7sually associated ith traumao Spinal ,ord .njury causes1

GJI !8A JGI 8iolence

JJI Falling HI Sports

o 9reat risks re6uires B-ray to pre/ent neurologic dysunction#o !ost oten treated ith closed reduction

,er/ical Fractureso !nemonic ;QI o unstable ,-Spine ractures#

ePerson:urst ,


36/54

FeltyWs syndrome is characteri=ed by )A$ splenomegaly$ and neutropenia ,an ha/e extra articular maniestations

Skin$ eyes$ lung$ 9.o D.A9(OS.S

)F .g! antibodies against Fc .g9# is seen in C [QI o cases2 'S) may also be seen2

Anemia o chronic disease2 Syno/ial luid aspirate shos turbid luid$ ] /iscosity$ and an %:, count EEEVQE$EEE cells0^4#2

o +reatment )adiographs1

'arly1 Sot tissue selling and juxta-articular deminerali=ation2 4ate1 oint space narroing and erosions2

+)'A+!'(+

(SA.Ds can be reduced or discontinued olloing successul treatment ith disease-modiyingantirheumatic drugs D!A)Ds#2

D!A)Ds should be started early2 First-line drugs are hydroxychloro6uine$ sulasala=ine$methotrexate$ and a=athioprine2 Second-line agents include rituximab anti-,DJE#$ and le?unomide2

unior )Ao A nonmigratory$ nonsuppurati/e mono- and polyarthritis ith bony destruc- tion that occurs in patients ected joints2 0trongl# associated =ith *B,522 )isk actors include male gender and a 3 amily history2o ".S+O)&0P'

+ypical onset is in the late teens and early JEs2 Presents ith atigue$ intermittent hip pain$ and 4:P thatorsens ith inacti/ity and in the mornings2

] spine ?exion 3 Schober test#$ loss o lumbar lordosis$ hip pain and sti>ness$ and ] chest expansion areseen as the disease progresses2

,nterior "veitisand heart block may occur2 Other forms of seronegative spond#loarthropath#must be ruled out$ including the olloing1

Reactive arthritisormerly knon as )eiterWs syndrome#1 A disease o young men2 +he characteristicarthritis$ u/eitis$ conjuncti/itis$ and urethritis usually ollo an inection ith ,ampylobacter$ Shigella$Salmonella$ ,hlamydia$ or 7reaplasma2

+soriatic arthritis1 An oligoarthritis that can include the D.P joints2 Associated ith psoriatic skinchanges and sausage-shaped digits dactylitis#2

o D.A9(OS.S "4A-:J[ in HQV;QI o cases2 )adiographs may sho used sacroiliac joints$ s6uaring o the lumbar /ertebrae$ de/elopment o /ertical

syndesmophytes$ and bamboo spine2 'S) or ,)P is in [QI o cases2

(egati/e )FR negati/e A(A2o +)'A+!'(+

(SA.Ds e2g2$ indomethacin# or painR exercise to impro/e posture and breathing2

+umor necrosis actor +(F# inhibitors or sulasala=ine can be used in reractory cases2

,er/ical Spondylosiso Spondylosis 5 :one spurs osteophytes# as a result o joint degenerationo 9enerali=ed disease o the cer/ical spine related to disk degenerationR myelopathy$ radiculopathy$ or both may

occur2o Occurs in elderly patients C QE yo2 Occurs more re6uently in !en C omen2o Patients oten present ith complaints o shoulder$ elbo$ rist$ or hand pain and may report headache i

upper cer/ical spine is a>ected# and sti> necko !ultiple ner/e roots may be in/ol/ed in radicular symptoms$ causing arm pain and distal paresthesias


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o !yelopathy may present ith radicular symptoms but also loss o balance$ broad-based gait$ and loerextremity eakness

o )e?exes are hypoacti/e in the upper extremity but hyperacti/e in the loerR possible :abinski re?ex andclonus

o Patients ith se/ere cord compression may demonstrate a positi/e 4hermitte sign$ here an electric-shock likesensation radiates don the spine or extremities ith certain mo/ements o the neck$ especially during ?exionand extension2

o ,auses +he causes o spinal stenosis may be di/ided according to compression rom anterior or posterior

structures2

Anteriorly$ herniated disks Ossifcation o the posterior longitudinal ligament OP44#R and osteophytic spurs rom the back o the

/ertebral bodies$ endplates$ or unco/ertebral joints are the common culprits o cord and rootcompression +he ligamentum ?a/um is the main culprit causing posterior compression$ losing its tension and

buckling into the canal as the disc degenerates anteriorly2

OP44 more common in asianso P'

Some o the common ones include the 4hermitte sign$ :abinski re?ex$ "o>mann sign$ Spurling sign$ andja jerk test2

3 :abinski sign is a poor prognosis2 !easure upper motor lesions here upard mo/ement o the greattoe is considered abnormal in adults hen the sole o the oot is stroked2

+he "o>mann sign is an upper extremity counterpart o the :abinski re?ex$ and it can be elicited by?icking the /olar surace o the third distal phalanx o relaxed and slightly ?exed fngers$ hich results in

pathologic ?exion o the thumb and index fnger Fig2


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Thoracic 0pine +horacic disc disease

o "erniated disco Degenerati/e diseaseo Tsee cer/ical and lumbar notesU

Scoliosiso 'ssentials

Adults ho seek medical treatment complain o issues related to the spinal cur/e and0or pain2 Adults may ha/e typical TSU-shaped or only single cur/es2

.n general$ omen seek medical attention more oten than do men2 A lateral cur/ature o the spine o C


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4umbar disc syndromeso "erniated disc

Defnition

A lumbar disc herniation is defned as a prolapse o the annulus fbrosis o the lumbar disc into thespinal canal causing compression o the neural elements or rank rupture o the annulus fbrosis ithextrusion o nucleus pulposus material into the spinal canal causing compression o the neuralelements2

,hemical radiculopathy 5 ner/e pain but not d0t compression2 +B 5 sealing tear$ exercise$ P+$ musclerelaxants

Symptoms

Oten preceded by days or eeks o back pain$ indicating damage to annulus around diskR rupturecauses pain don leg into ner/e root distribution sciatica in GEI o patients#R ;EI are 4QVS< or 4GV4Qdisks2

:esides pain$ common symptoms include numbness$ pins and needles$ and tingling2

(er/es compressed 4G$ 4Q or S< ner/e roots#R this ould typically cause pain that starts in the buttockand goes don the posterior aspect o the thigh into the cal and into the oot2 !any patients ill notethat sitting is their most uncomortable position and that standing and lying don are morecomortable or them

,omplications1

8ery rarely$ a massi/e disc herniation can compress all o the ner/es in the spinal canal at that le/el$including the loer sacral ner/e rootsR such a situation$ knon as cauda e6uina syndrome$ ill producese/ere pain don both legs$ signifcant derangement in boel and bladder unction incontinence orretention#$ and Tsaddle anesthesiaU numbness in the buttocks around the anus and genitals and in theinner aspects o the thighs#2 Se/ere eakness may also accompany this syndrome2

)'*7.)' S7)9.,A4 D',O!P)'SS.O( !edical emergency

P' and lab fndings

3 straight leg test radiculopathy#

3 emoral stretch laying on table prone ith extension o a>ected leg#

8alsal/a maneu/er reproduces pain by increasing intraabdominal pressure2

)e?ex tests

4G compression 5 ha/e eakness o ankle dorsi?exion$ some diKculty alking on the heels$ and adiminished patella tendon re?ex on that side2

4Q compression 5 unable to alk on heels

S< compression 5 eakness o the gastroc-soleus muscle group ith diKculty alking on the toesor doing repeated toe raisesR there may be a diminished Achilles tendon re?ex2

.maging

!). shos high intensity =ones hen disc is dehydrated appears black#2 ,an produce loer backpain2 Diagnosed by Discography . !). is contraindicated pacemaker0obese#$ use ,+ 3 myelogram2

B ray is useul to rule out a structural abnormality o the spine such as scoliosis$ spondylolisthesis$or a ractureR it ill not$ hoe/er$ sho anything but the osseous structures and ill thereore notsho a lumbar disc herniation2

+reatment

!ost ill spontaneously resol/e ithin G-M eeks2

Symptomatic 5 (SA.Ds$ P+$ short term oral steroids$ or epidural steroid injections2

.n se/ere cases progressi/e neuro defcits0chronic pain0cauda e6uina#$ re6uire surgery2 +he standardoperation or a lumbar disc herniation is a laminectomy-discectomy2 +his typically in/ol/es an incisionapproximately


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Finally$ suggestion o disc degeneration is oten e/ident by loss o space beteen /ertebra andassociated osteophyte ormation$ particularly in the anterior aspect o the /ertebral bodies2

!ore accurate suggestion o degenerati/e disc disease is by ay o !). studiesR sagittal +J-eightedimages are particularly useul to e/aluate disc height and hydration %hen disc degeneration is se/ere$ changes ithin the endplates o the /ertebral bodies may be

seen$ ith edema noted in the area o the endplates o the /ertebral body !odic changes#2 +reatment

!ainstay is (SA.DS$ steroid injections$ and P+2

Surgery benefts /s2 risks#

Fusion o 4Q and S phase o running

athletes and demi-pointe position in dancers$ shoes ith narro toe box or high heels can make symptomsorse $ patients oten complain o eeling like there is a stone or similar under the ball o their oot2 GEI reportsnumbness or dysesthesia in plantar aspect o eb space2

P'- plantar tenderness ith palpation just distal to metatarsal heads$ check sensation in a>ected region as it maybe altered in some patients$ a bursal click !ulder@s click# may be elicited by s6uee=ing metatarsals together$ ormetatarsalgia and !+P syno/itis or instability must be ruled out use draer test at !+P#2

+x1 (onoperati/eo =ide shoe )ox =ith Hrm sole and metatarsal pad

indications

frst line o treatmento corticosteroid in!ection

usually approached dorsal ner/e is belo intermetatarsal ligament a/oid injection o !+P due to risk o iatrogenic instability

+B1 Operati/eo ne"roma resection

indications

hen nonoperati/e management ails

techni6ue dorsal incision used most commonly

resection o neuroma J- cm proximal to deep trans/erse intermetatarsal ligament incise trans/erseintermetatarsal ligament#

bury proximal stump ithin intrinsic muscleso ne"roma decompression

alternati/e to resection$ especially i adjacent neuromas

resection o adjacent neuromas ill lead to complete numbness o toe

Metatarsalgia *all"x valg"s1

o (ot a single deormity$ but rather a complex deormity o the frst rayR oten accompanied by deormities andsymptoms in lesser toe2


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o +o orms exist - adult hallux /algus and adolescent N ju/enile hallux /algus2o Pathoanatomy- /algus de/iation o phalanx promotes /arus position o metatarsalR the metatarsal head

displaces medially$ lea/ing the sesamoid complex laterally translated relati/e to the metatarsal headRsesamoids remain ithin the respecti/e head o the ?exor hallucis bre/is tendon and are attached to the baseo the proximal phalanx /ia the sesamoido-phalangeal ligamentR this lateral displacement can lead to transermetatarsalgia due to shit in eight bearingR medial !+P joint capsule becomes stretched and attenuatedhile the lateral capsule becomes contractedR adductor tendon becomes deorming orceR inserts on fbularsesamoid and lateral aspect o proximal phalanxR lateral de/iation o '"4 urther contributes to deormityRplantar and lateral migration o the abductor hallucis causes muscle to plantar ?ex and pronate phalanxRindlass mechanism becomes less e>ecti/eR leads to transer metatarsalgia 2

o Presentation-presents ith diKculty ith shoe ear due to medial eminence$ pain o/er prominence at !+Pjoint$ compression o digital ner/e may cause symptoms

o Physical exam "allux rests in /algus and pronated due to deorming orces illustrated abo/e 0 examine entire frst ray or


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*all"x rigid"s W9 DD35o A condition characteri=ed by loss o motion o frst !+P joint in adults due to degenerati/e arthritis1 osteophyte

ormation leads to dorsal impingement2o Pathoanatomy - primary etiology unknon$ acute trauma and repetiti/e microtrauma predispose to arthritic

changes$ anatomic /ariations o frst metatarsal may play a yet unpro/en role in arthritic predisposition2o Symptoms1 frst ray and or orced dorsi?exion o great toe$ shoe

irritation due to dorsal osteophytes and compression o dorsal cutaneous ner/e may lead to paresthesias$ pain

becomes less se/ere as the disease progresses2o Physical exam5limited dorsi?exion$ pain ith grind test2o +x1

o Nonoperative1 (SA.DS$ acti/ity modifcation N orthotics

.ndications 5 grade E and < disease acti/ity modifcations

a/oid acti/ities that lead to excessi/e great toe dorsi?exion types o orthotics

!orton@s extension ith sti> oot plate is the mainstay o treatment

sti> sole shoe and shoe box stretching may also be usedo Operative1

o joint debridement and syno/ectomy indications 5 patients ith acute osteochondral or chondral deects

o dorsal cheilectomy indications

grade < and J disease contro/ersial# pain ith dorsi?exion is an indicator o good results ith dorsal cheilectomy

shoe ear irritation rom dorsal prominence and pain ideal candidate#

contraindicated hen pain located in the mid-range o the joint during passi/emotion

techni6ue

remo/e JQ-EI o the dorsal aspect o the metatarsal head along ith dorsalosteophyte resection

the goal o surgery is to obtain [EI to ;EI dorsi?exion intraoperati/ely

o !oberg procedure dorsal closing edge osteotomy o the proximal phalanx# indications

runners ith reduced dorsi?exion ME\ is needed to run#

ailure o cheilectomy to pro/ide at least E to GE degrees o motion techni6ue

increases dorsi?exion by decreasing the plantar ?exion arc o motiono eller Procedure resection arthroplasty#

indications

elderly$ lo demand patients ith signifcant joint degeneration and loss o motion

contraindicated in patients ith pre-existing rigid hyperextension deormity o $ and transermetatarsalgia decreased ith capsular interposition#

o !+P arthroplasty indications contro/ersial techni6ue

capsular interpositional arthroplasty gaining popularity silicone implants are not recommended due to poor long-term results

outcomes

silicone implants may ha/e a good short term satisaction rate

osteolysis and syno/itis cause mid to long term pain and joint destructiono !+P joint arthrodesis

indications

grade and G disease signifcant joint arthritis#

most common procedure or hallux rigiduso outcomes

[EI to


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ongenital overlapping of the Hfth toe7

A congenital deormity charactei=ed by a Qth toe that o/erlaps the ourth -condition is usually bilateral2

!ay cause problems ith shoeear

+reatment1 (onoperati/e -initial treatment is passi/e stretching and buddy taping

Operati/e 1 tenotomy$ dorsal capsulotomy$ syndactyli=ation the the ourth toe !cFarland procedure#

*ammertoe7 "ammer deormity characteri=ed by ?exion o the P.P joint$ extension deormity at D.P$ deormity can be rigid or

?exible2 !ost common deormity o lesser toes2 !ore common in older omen2 Second toes usually a>ected2

Pathoanatomy -o/erpull o 'D4 $ imbalance o intrinsics2 Sx1 pain on dorsal surace ith shoe$ Push up test 1?exible deormity is reducible ith dorsal directed pressure onthe plantar aspect o the in/ol/ed metatarsal-e>ect o o/er acti/e extrinics is remo/ed2

+x1 (onoperati/eo shoes =ith high toe )oxes$ foam or silicone gel sleeves

indications 5 pain and or corns on dorsal P.P Operati/e

o Gexor tendon /DB3 to extensor tendon transfer indications 5 ?exible deormity that has ailed nonoperati/e management

o resection arthroplast# Q95 tenotom# and tendon transfers indications

rigid deormity that has ailed nonoperati/e mangement 0o girdlestone proced"re =ith Gexor to extensor transfer

indications

!+P in/ol/ement similar to cla toe treatment

o arthrodesis indications 5 an option in rigid deormity outcomes 5 high nonunion rate

corns and call"ses5 =ill Hnish

plantar =arts5 =ill Hnish

disorder of the toenail5 =ill Hnish

K. -xplain the diPerence )et=een sta)le vs "nsta)le ankle fract"resfoc"sing on their radiographicHndings and treatment Stable ractures in/ol/e only < side o the ankle2 7nstable in/ol/e both sides o the ankle bimalleolar# or both

sides and posterior malleolus trimalleolar#2o A x o distal fbula in conjunction ith tenderness o/er deltoid ligament medially is most likely an unstable

bimalleolar x2o +x- stable distal fbula ractures x# can be treated 0 eight bearing cast or brace or G-M ks2

7nstable but non displaced x re6 a non-t bearing short or long leg case and longer immobili=ation2 7nstabledisplaced x re6 closed or open reduction$ but better alignment is obtained 0 open reduction and internal fxation2Any dislocation needs to be reduced$ along ith O).F2

J. Disc"ss the mechanisms of in!"r# and treatment methods for the follo=ing conditions7alcaneal fract"res5 traumatic axial loading is primary mech o injury all rom height$ !8As#R+reatment includes1Nonoperative-cast immobili=ation ith noneightbearing or M eeks 0

o indications

calcaneal stress ractures

cast immobili=ation ith noneightbearing or


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o techni6ues

lag scres rom posterior superior tuberosity directed inerior and distal

O).F

o indications

large extra-articular ractures C< cm# ith detachment o Achilles tendon and0or C J mm

displacement

urgent i skin is compromised

Sanders +ype .. and ...

posterior acet displacement CJ to mm$ ?attening o :ohler angle$ or /arus

malalignment o the tuberosity anterior process racture ith CJQI in/ol/ement o calcaneocuboid joint

displaced sustentaculum ractures

o timing

ait


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sagittal plane deormity more than


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o extraarticular ith Y


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0ho"lder1.Identif# the anatom# and disc"ss the ph#sical exam tests for the rotator c"P tendon7

Overvie= of +h#sical -xam of Rotator "P

Cuf Muscle Strength Testing Special Tests

Supraspinatus %eakness to resisted ele/ation in obe position Drop arm test

Pain ith obe test

.nraspinatus ') eakness at E\ abduction ') lag sign

+eres minor ') eakness at ;E\ abduction and ;E\ ') "ornbloers

Subscapularis .) eakness at E\ abduction 'xcessi/e passi/e ')

:elly press 0

4it o> 0

.) lag sign

. Disting"ish )et=een the follo=ing7a3 tendonitis5)3 rotator c"P tears-

o most oten occurs at insertion o myo into greater tuberosityR

o acute tears present ith sudden onset o pain related to acute injury$

o chronic tears present ith no hx o injury in older pt2

o DiKculty 0o/erhead acti/itiesR grinding0grating0catching sensation 0 mo/t o shoulderR complaints o

nocturnal pain orse than daytime pain and diKculty sleeping on a>ected shoulder$ pain locali=ed todeltoid region and rarely radiaties past elbo2

o P'- tenderness to palpation o/er greater tuberosity$ pain 0 orced internal rotation and orard?exion$ presence o pain and eakness 0 empty can test$ atrophy may be noted in posterior shoulder$P)O! may remain ull but limitation in abduction to around GQdeg ith A)O!R shoulder xr re/ealhooked acromion hich predisposes to tears$ shoulder xr in long term chronic tears may re/eal loss osubacromial space$

o !). to confrm and assess extent o tear2

o (SA.DS or acute pain$ P+ or preser/ing rom$ stretching$ strengthening2 udicious use o corticosteroidinjections

c3 calciHc tendonitis5

%. DeHne adhesive caps"litis and disc"ss its ph#sical exam Hndings$ diagnostic eval"ation$ diPerentialdiagnosis$ treatment and prognosis +x1 ,odmanWs exercises1 sing arm in pendulum motion ith light handheld eights or f/e minutes


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o presents ith traumatic injury to acromion$ pt usually supporting injured arm in adduction$ motion espabduction o shoulder causes pain$ pain o/er A, jt and pain hen attempting to lit a>ected arm2

o P'- tenderness o/er A, jt$ grade J- usually ha/e small amt o deormity o/er A, jtR grade - ha/e

marked deormity o/er A, jt2 A, jt idening on a>ected side in grade J or higher2

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