Diagnostic Diagnostic ImagingImaging

Lecture 3Lecture 3MusculoskeletalMusculoskeletal

Musculoskeletal InjuriesMusculoskeletal InjuriesMusculoskeletetal problems commonly Musculoskeletetal problems commonly occur as a occur as a resultresult of both of both serious athletic serious athletic pursuits and activities of daily livingpursuits and activities of daily living..Most sports and recreational injuries Most sports and recreational injuries are the results of:are the results of:– contusions, contusions, – sprains (ligamentous injuries), sprains (ligamentous injuries), – strains (musculotendinous injuries), strains (musculotendinous injuries), – meniscal injuries, meniscal injuries, – bursitis, bursitis, – fractures, and fractures, and – dislocations.dislocations.

Physical therapy is an important adjunct Physical therapy is an important adjunct to the management of these disorders to the management of these disorders

Skeletal Imaging

Majority by plain radiographAP and Lateral projectionsOblique views for trauma involving joints, hands and feetCT - fine bone structure ( skull,spine and pelvis)MRI - evaluation of soft tissueNuclear medicine - bone metastases, differentiate cellulitis from osteomyelitis and occult trauma (stress fractures)

Skeletal Imaging

Most bone lesions are obvious on clinical history

>95 % bone films are obtained for:– Evaluation of trauma– Eval. Arthritis– Eval. Degenerative conditions– Metastases

SprainsSprainsSprainsSprains are are ligament injuriesligament injuries. .

Ligaments attach bone to boneLigaments attach bone to bone

Ligaments are like Ligaments are like strong cords, tough and strong cords, tough and elasticelastic, and , and provide stabilityprovide stability and and strengthstrength between jointsbetween joints, but when pulled or stretched to , but when pulled or stretched to their limit their limit they can tear or rupture.they can tear or rupture.

Depending on the amount of ligament tearing, Depending on the amount of ligament tearing, a a sprainsprain can be can be mild, moderate, or severe. mild, moderate, or severe.

An An alternatealternate classification is; a classification is; a first-degreefirst-degree, , second-degree or third-degree sprain.second-degree or third-degree sprain.

SprainsSprains

1rst degree - joint pain / tenderness - no laxity

2nd degree - joint laxity present - pain and tenderness

3rd degree - ligament broken - unstable joint

SprainsSprainsMost sprains are Most sprains are associatedassociated with with varyingvarying degrees of degrees of pain, swelling and impairment of range-of-motion or pain, swelling and impairment of range-of-motion or weight bearing.weight bearing.

The The most commonly most commonly involved areas are the involved areas are the shoulder, the shoulder, the elbow, the knee and the ankleelbow, the knee and the ankle..

Knee and ankle sprains are among the most common of Knee and ankle sprains are among the most common of all sports injuries. all sports injuries.

If the physical exam is difficult to perform or damage to If the physical exam is difficult to perform or damage to other intra-articular structures is suspected, an other intra-articular structures is suspected, an MRI can MRI can help determine the full extent of injury. help determine the full extent of injury.

StrainsStrainsA A strainstrain is the is the tearing of a muscle-tendon unit. tearing of a muscle-tendon unit.

termed termed tendonitistendonitis

acute or chronicacute or chronic

causedcaused by by overuseoveruse or a single or a single episode of episode of overactivityoveractivity

pain results from minor tears in the tendonspain results from minor tears in the tendons, , from accumulated injuries (from accumulated injuries (repetitive micro-repetitive micro-traumatrauma) that outpace the body’s ability to repair ) that outpace the body’s ability to repair itself.itself.

StrainsStrainsmay result may result in pathologic changes of the in pathologic changes of the soft-tissue and bones:soft-tissue and bones:– tendon degeneration, osteophytes, stress tendon degeneration, osteophytes, stress

fractures, or nerve entrapmentfractures, or nerve entrapment. .

also graded as mild, moderate or also graded as mild, moderate or severe.severe.Severe strains are characterized by Severe strains are characterized by rupture of any part of the tendon rupture of any part of the tendon complex e.g biceps, patella or Achilles. complex e.g biceps, patella or Achilles.

TerminologyTerminologyFractureFracture is a is a break or loss of structural break or loss of structural continuity in a bone. continuity in a bone. – it is important that fractures be described in a it is important that fractures be described in a

precise and detailed manner.precise and detailed manner.

Dislocation and SubluxationDislocation and Subluxation alters the normal alters the normal relationship between joint surfaces.relationship between joint surfaces.

– DislocationDislocation : :the normally the normally apposing apposing joint joint surfacessurfaces completely completely loose contactloose contact

– SubluxationSubluxation : :those surfaces those surfaces are only are only partially separatedpartially separated..

Fractures are described Fractures are described

DescriptionDescription

FractureFracturedisplacementdisplacement

FractureFractureAngulation Angulation

dorsal volardorsal volar

FractureFractureRotationRotation

FractureFracture

BayonetingBayoneting

FractureFractureDistractionDistraction

FractureFractureObliqueOblique

FractureFractureGreenstickGreenstick

FractureFractureTransverseTransverse

FractureFractureComminutedComminuted

FractureFractureSpiralSpiral

FractureFractureDislocationDislocation

FractureFractureNonunionNonunion MalunionMalunion

FractureFractureAvulsionAvulsion

FracturesFractures

Fractures are Fractures are open or closedopen or closed. .

OpenOpen: : breakbreak in the surrounding in the surrounding skin or mucosa skin or mucosa that allows the fracture to that allows the fracture to communicate communicate with the with the external external environment.environment.

Open fractures are graded 1-3, with Open fractures are graded 1-3, with 33 being the being the most severemost severe, and having the , and having the highesthighest incidence incidence of of complicationscomplications (e.g. osteomyelitis and (e.g. osteomyelitis and nonunion).nonunion).

Open fracturesOpen fracturesGrade 1:Grade 1: wounds < 1cm in length wounds < 1cm in length Grade 2:Grade 2: wounds > 1cm in length wounds > 1cm in length

but clean w/o devitalization of tissuebut clean w/o devitalization of tissueGrade 3: Grade 3: wounds > 1 cm in length, wounds > 1 cm in length,

grossly contaminated, grossly contaminated, associated with comminuted associated with comminuted

fractures and fractures and vascular vascular injury.injury.Open fracturesOpen fractures - - surgical emergenciessurgical emergencies

debrideddebrided, , irrigatedirrigated (parenteral antibiotics(parenteral antibiotics within 6 hours)within 6 hours)

Fracture DescriptionFracture DescriptionFraFractures are ctures are further describedfurther described based on: based on:– LocationLocation– PatternPattern– DisplacementDisplacement

When describing When describing locationlocation, , – the the bone affectedbone affected is identified is identified – as well as the as well as the specific part of the bone specific part of the bone involved (involved (proximal or proximal or

distal epiphysis,etcdistal epiphysis,etc.).)

Fracture location has implication for healing. Fracture location has implication for healing. – Fractures of metaphyseal or cancellous bone usually heal Fractures of metaphyseal or cancellous bone usually heal

quite rapidly in contrast to cortical or diaphyseal bone, which quite rapidly in contrast to cortical or diaphyseal bone, which heals more slowly due to differences in blood supply and heals more slowly due to differences in blood supply and bone turnover rate. bone turnover rate.

(Physis)

Fracture PatternFracture PatternThe The fracture pattern fracture pattern relates to fracture relates to fracture geometry, which suggests the geometry, which suggests the typetype and and amountamount of of kinetic energykinetic energy the the bonebone has has been been subjected toosubjected too..– A A transversetransverse fracture is a fracture is a low-energy injurylow-energy injury, ,

usually the result of either a direct blow to a usually the result of either a direct blow to a long bone or a ligament avulsion. long bone or a ligament avulsion.

An example is a “night stick” fracture, which An example is a “night stick” fracture, which involves the ulna and occurs when the forearm is involves the ulna and occurs when the forearm is used to defend against an assault. used to defend against an assault.

Stress and pathologic fractures Stress and pathologic fractures usually usually have a have a transverse patterntransverse pattern..

Fracture PatternFracture PatternSpiral or obliqueSpiral or oblique fractures result from a fractures result from a rotatory rotatory or twisting injury. or twisting injury. – These fractures have a tendency to displace after These fractures have a tendency to displace after

reduction and immobilization.reduction and immobilization.– Spiral or oblique fractures typically require ORIF. Spiral or oblique fractures typically require ORIF.

A A fracture with two or more fragments fracture with two or more fragments is termed is termed comminutedcomminuted. . – Subtypes are called butterfly fragments and Subtypes are called butterfly fragments and

segmental fractures. segmental fractures.

Fracture PatternFracture PatternAn An impactedimpacted fracture is commonly seen in fracture is commonly seen in metaphyseal bone, such as the metaphyseal bone, such as the femoral neckfemoral neck, , the distal radius or tibial plateau fractures.the distal radius or tibial plateau fractures.– These (impacted) are low-energy injuries in which These (impacted) are low-energy injuries in which

two bone fragments are jammed togethertwo bone fragments are jammed together..

Fractured bone fragments can be displaced Fractured bone fragments can be displaced due to the force of the injury, gravity, or muscle due to the force of the injury, gravity, or muscle pull. pull.

DisplacementDisplacement is is describeddescribed in terms of in terms of angulation, rotation and lengthangulation, rotation and length. .

Salter-Harris Salter-Harris (Growth Plate) (Growth Plate) FracturesFractures

Growth plate fractures in children Growth plate fractures in children are based on are based on the Salter-Harris classification of injuries. the Salter-Harris classification of injuries.

Growth plate injuries, no matter how trivial, Growth plate injuries, no matter how trivial, have the have the potential to cause growth disturbance potential to cause growth disturbance of the involved bone. of the involved bone.

These fractures are classified as These fractures are classified as type I-Vtype I-V. .

Salter-Harris ClassificationSalter-Harris ClassificationType I- through the physis.

Type II- through the physis and metaphysis.

Type III- through the physis and epiphysis.

Type IV- through the physis, metaphysis and epiphysis.

Type V- crush injury to the physis.

Principles of fracture management:Principles of fracture management:

Patients with fractures Patients with fractures should be managed as trauma should be managed as trauma patients.patients.always always check for associated injuries (check for associated injuries (ABC’sABC’s).).Next, Next, assess the assess the neuro-vascular statusneuro-vascular status..Remember to check :Remember to check :– distal pulses and capillary refill.distal pulses and capillary refill.– sensory and motor functionsensory and motor function (distal to the fracture )(distal to the fracture )

Fracture managementFracture management

The three principles of fracture care The three principles of fracture care involve: involve:

1) Reduction of deformity 1) Reduction of deformity

2) Maintenance of reduction2) Maintenance of reduction

3) Rehabilitation of function3) Rehabilitation of function

Closed reductionClosed reduction

ReductionReduction – ClosedClosed – OpenOpen

ClosedClosed reduction: involves the reduction: involves the manual manual manipulationmanipulation of the fracture of the fracture intointo a a functional functional position.position.– tractiontraction is is appliedapplied – deforming forces deforming forces are are reversedreversed – realignrealign the the bone fragmentsbone fragments. .

Open reductionOpen reductionopen reduction open reduction – fracture is fracture is surgically surgically exposed exposed – bone fragments bone fragments are are manipulated directlymanipulated directly

(ORIF=open reduction and internal fixation).(ORIF=open reduction and internal fixation).

Open reduction Open reduction indicatedindicated when: when:– closedclosed reduction reduction methods fail methods fail – with with intra/articular fracturesintra/articular fractures (joint surface must be (joint surface must be

aligned anatomically to prevent the development of aligned anatomically to prevent the development of posttraumatic arthritis.posttraumatic arthritis.

Maintaining alignmentMaintaining alignmentMaintaining alignment requiresMaintaining alignment requires ImmobilizationImmobilization: : – include include castingcasting, , splintingsplinting, , tractiontraction, , functional bracingfunctional bracing, and , and

internal or external fixation.internal or external fixation.

The type of immobilization depends upon fracture The type of immobilization depends upon fracture stability or its propensity for displacement. stability or its propensity for displacement. Splints and casts Splints and casts immobilizeimmobilize and and support support the injured the injured extremity and thereby extremity and thereby reduce painreduce painprevent injuryprevent injury to to structuresstructures in the in the proximity of a proximity of a fracturefracture, and , and maintain alignment after reductionmaintain alignment after reduction..Splinting and casting are Splinting and casting are alsoalso used used postoperatively postoperatively to to provide provide additional stabilization additional stabilization when when fixationfixation is is tenuoustenuous. .

Splinting and castingSplinting and casting

Splinting and casting accomplished with plaster Splinting and casting accomplished with plaster or synthetic materials such as fiberglass.or synthetic materials such as fiberglass.

Splints differ from casts in that Splints differ from casts in that splintssplints are not are not circumferentialcircumferential and thus allow swelling of the and thus allow swelling of the extremity without a significant increase in extremity without a significant increase in pressure within the splint.pressure within the splint.

Swelling within the cast Swelling within the cast increases pressure, increases pressure, potentially resulting in a potentially resulting in a compartment compartment syndrome or pressure sores.syndrome or pressure sores.

Splinting and castingSplinting and castingMany of the Many of the fundamental rules of splinting and fundamental rules of splinting and castingcasting are identical. are identical.Ideally, at least Ideally, at least one joint proximal and one joint one joint proximal and one joint distal to the injury are immobilizeddistal to the injury are immobilized..Prior to immobilization, fractures are Prior to immobilization, fractures are reducedreduced, , and, as much as possible are placed in a and, as much as possible are placed in a position of functionposition of function..The extremity and bony prominences are The extremity and bony prominences are padded to prevent pressure sores and padded to prevent pressure sores and neurovascular compression.neurovascular compression.

ComplicationsComplications

Common complications of musculoskeletal Common complications of musculoskeletal injuries:injuries:

– ARDS (fat embolism)ARDS (fat embolism)

– DVTDVT

– AtelectasisAtelectasis

– Nerve compressionNerve compression

– Osteomyelitis Osteomyelitis

ShoulderShoulder

NormalNormal

Acromioclavicular (AC) separation Acromioclavicular (AC) separation (separated shoulder)(separated shoulder)

Mechanism of injury- Mechanism of injury- fall onto point of shoulderfall onto point of shoulderIf there has been significant disruption (or a fracture to If there has been significant disruption (or a fracture to the clavicle itself), the area will appear swollen and the clavicle itself), the area will appear swollen and deformed compared with the other side. deformed compared with the other side. The patient will avoid movement, due to pain. The patient will avoid movement, due to pain. Gently have the patient move their arm across their Gently have the patient move their arm across their chest while you palpate in the AC region. chest while you palpate in the AC region. – This will cause pain specifically at the AC joint if This will cause pain specifically at the AC joint if

there is separation.there is separation. Tenderness is felt at the junction, or the site of the AC Tenderness is felt at the junction, or the site of the AC (acromioclavicular) joint(acromioclavicular) joint. .

AC separation (cont)AC separation (cont)Grade I: Grade I: – AC AC ligament sprainedligament sprained, but , but joint joint remains remains intactintact

Grade II:Grade II:– RuptureRupture of AC of AC ligamenligament and t and joint separationjoint separation

Grade III:Grade III:– Coracoclavicular and AC ligaments ruptured Coracoclavicular and AC ligaments ruptured with with wide wide

separation of jointseparation of joint

Tx:Tx:– Grade I-II: sling, ice x 2 wks then ROMGrade I-II: sling, ice x 2 wks then ROM– Grade III: sling, ice x several wks until pain subsides, then Grade III: sling, ice x several wks until pain subsides, then

ROM & strengthening vs. surgical repairROM & strengthening vs. surgical repair

Anterior Glenohumeral Dislocation Anterior Glenohumeral Dislocation “Shoulder dislocation”“Shoulder dislocation”

Mechanism of injury:Mechanism of injury:– From From external rotation & abduction force on humerusexternal rotation & abduction force on humerus– From a direct posterior blow to proximal humerusFrom a direct posterior blow to proximal humerus– From a posterolateral blow on the shoulderFrom a posterolateral blow on the shoulder

Exam:Exam:– Space underneath acromion where humeral head should lieSpace underneath acromion where humeral head should lie– Palpable anterior mass representing humeral head in Palpable anterior mass representing humeral head in

anterior axillaanterior axilla

Tx:Tx:– Closed reductionClosed reduction– Immobilization in internal rotationImmobilization in internal rotation

Shoulder dislocationShoulder dislocation

------Normal------Normal

Shoulder dislocation->Shoulder dislocation->

Anterior Anterior dislocationdislocation

– (Much (Much more more common common than than posterior posterior dislocation)dislocation)

Posterior Posterior

dislocationdislocation

Anterior Glenohumeral Dislocation Anterior Glenohumeral Dislocation ComplicationsComplications

2 lesions with recurrent dislocations:2 lesions with recurrent dislocations:

– Bankhart LesionBankhart Lesion::Anterior capsular injury assoc with a tear of the glenoid Anterior capsular injury assoc with a tear of the glenoid labrum off the anterior glenoid rimlabrum off the anterior glenoid rim

– Hill-Sachs DeformityHill-Sachs Deformity::Compression fracture of the articular surface of the Compression fracture of the articular surface of the humeral head posterolaterally that is created by the sharp humeral head posterolaterally that is created by the sharp edge of the anterior glenoid as the humeral head edge of the anterior glenoid as the humeral head dislocates over itdislocates over it

Hill-Sachs Deformity

Clavicle fractureClavicle fractureMost common bone fracturedMost common bone fracturedWeakest aspect is junction of middle/distal thirds Weakest aspect is junction of middle/distal thirds Look for “Look for “TentingTenting” of the skin” of the skinClass A (middle third fractures) (80%)Class A (middle third fractures) (80%): : – Treat with sling immobilization. Treat with sling immobilization. – Some prefer using a figure-eight clavicular splint, especially for displaced Some prefer using a figure-eight clavicular splint, especially for displaced

fractures.fractures.

Class B (distal third fractures) (15%): Class B (distal third fractures) (15%): – Treat type I (nondisplaced) and type III (articular surface) fractures with Treat type I (nondisplaced) and type III (articular surface) fractures with

sling immobilization. sling immobilization. – Immobilize type II (displaced) fractures in a sling and swathe. Immobilize type II (displaced) fractures in a sling and swathe. – These may require orthopedic surgical fixation.These may require orthopedic surgical fixation.

Class C (proximal third) (5%): Class C (proximal third) (5%): – Treat nondisplaced fractures with sling immobilization. Treat nondisplaced fractures with sling immobilization. – Displaced injuries may require orthopedic referral for surgical reduction. Displaced injuries may require orthopedic referral for surgical reduction. – Neonatal fractures generally heal spontaneously in several weeks Neonatal fractures generally heal spontaneously in several weeks

without special treatment.without special treatment.

Normal---Normal---

-----Normal-----Normal

Fracture----Fracture----

Shoulder FracturesShoulder FracturesProximal Humerus FracturesProximal Humerus Fractures::– Neer classificaton:Neer classificaton:

Non-displaced fractures: Non-displaced fractures: – are displaced less than 1cm or angulated <45 are displaced less than 1cm or angulated <45

degrees, regardless of the fracture pattern or # of degrees, regardless of the fracture pattern or # of fragmentsfragments

Displaced fractures:Displaced fractures:– 2 part fx’s2 part fx’s are fractured either through the anatomical are fractured either through the anatomical

neck, surgical neck, greater tuberosity or lesser neck, surgical neck, greater tuberosity or lesser tuberositytuberosity

– 3 part fx’s3 part fx’s are fx’s of the surgical neck with fractures of are fx’s of the surgical neck with fractures of either the greater tuberosity or lesser tuberosityeither the greater tuberosity or lesser tuberosity

– 4 part fx’s4 part fx’s are fxs of the anatomic neck & fractures of are fxs of the anatomic neck & fractures of the greater and lesser tuberositiesthe greater and lesser tuberosities

Proximal Humerus FractureProximal Humerus Fracture

The vascularity is at risk with anatomical neck The vascularity is at risk with anatomical neck fracturesfracturesMost common Most common mechanism of injury= mechanism of injury= FOOSHFOOSHSigns & symptoms:Signs & symptoms:– Pain, swelling, tenderness Pain, swelling, tenderness

Tx:Tx:– For nondisplaced fx’s= sling, begin ROM exercisesFor nondisplaced fx’s= sling, begin ROM exercises– 2 part/3 part fx’s= closed reduction, sling, possible 2 part/3 part fx’s= closed reduction, sling, possible

ORIFORIF– Absolute indication for hemi-arthroplasty: 4 part fx’s, Absolute indication for hemi-arthroplasty: 4 part fx’s,

non-reducible 3 part fx’snon-reducible 3 part fx’s

Midshaft Humerus FracturesMidshaft Humerus FracturesSigns & Symptoms:Signs & Symptoms:– Arm pain, swelling, deformityArm pain, swelling, deformity– The arm is shortened with gross motion & crepitus on gentle The arm is shortened with gross motion & crepitus on gentle

manipulationmanipulation

XR:XR:– AP/lat c shoulder & elbowAP/lat c shoulder & elbow

Tx:Tx:– Coaptation splintCoaptation splint

Carefully molded plaster slab placed around medial & lateral aspects Carefully molded plaster slab placed around medial & lateral aspects of arm, extending from axilla around elbow & over deltoid & acromion of arm, extending from axilla around elbow & over deltoid & acromion x 2 wksx 2 wks

– Change to Sarmiento brace @ 2 wksChange to Sarmiento brace @ 2 wks– May require ORIF with plate/screw or intramedullary nailingMay require ORIF with plate/screw or intramedullary nailing

Midshaft humerus fxMidshaft humerus fx

Elbow FracturesElbow FracturesMonteggia FractureMonteggia Fracture– Usually a Usually a fx of the proximal Ulna with anterior fx of the proximal Ulna with anterior

dislocation of the radial headdislocation of the radial head– MOI:MOI:

Forceful pronation or direct blow to dorsum of ulnaForceful pronation or direct blow to dorsum of ulna

– H&P:H&P:Pain & h/o trauma, may have obvious deformityPain & h/o trauma, may have obvious deformity

– XR:XR:AP/lat/obliqAP/lat/obliq

– TX:TX:Hematoma block, reduction, long arm cast or splintHematoma block, reduction, long arm cast or splint

May require ORIFMay require ORIF

Galeazzi Galeazzi Fracture/dislocationFracture/dislocation

involving distal involving distal radial shaft fracture with associated radial shaft fracture with associated dislocation of the distal radioulnar jointdislocation of the distal radioulnar joint (DRUJ), which (DRUJ), which disrupts the forearm axis joint. disrupts the forearm axis joint.

"fracture of necessity" refers to the adult Galeazzi "fracture of necessity" refers to the adult Galeazzi fracture not being amenable to treatment by closed fracture not being amenable to treatment by closed means, necessitating surgical stabilization. means, necessitating surgical stabilization.

Galeazzi Galeazzi (Reverse Monteggia)(Reverse Monteggia)

GaleazziGaleazzi

Radial Head FractureRadial Head FractureMOI:MOI:– Fall forward with elbow extended, forearm pronatedFall forward with elbow extended, forearm pronated

Pain localized to radial headPain localized to radial head

XR:XR:– AP/lat/obliqAP/lat/obliq– If fracture is subtle, look for If fracture is subtle, look for “fat pad, or sail sign’s”“fat pad, or sail sign’s”

TX:TX:– Types I, II, & III without mechanical block are treated with a Types I, II, & III without mechanical block are treated with a

sling and AROM x 3 wkssling and AROM x 3 wks– After 3 wks d/c sling & begin aggressive PTAfter 3 wks d/c sling & begin aggressive PT– Fx’s with elbow instability or mechanical block are treated Fx’s with elbow instability or mechanical block are treated

operatively with either reduction & fixation of head, excision operatively with either reduction & fixation of head, excision of head, or ligament repairof head, or ligament repair

Normal Elbow

Radial head fx

Olecranon FracturesOlecranon FracturesPain @ elbow with h/o traumaPain @ elbow with h/o trauma

XR:XR:– AP/lat/obliqAP/lat/obliq

ManagementManagement– Initial: sling for comfortInitial: sling for comfort– Definitive: Definitive:

non-displaced fx’s can be managed with posterior non-displaced fx’s can be managed with posterior splint @ 90 degrees flexion x 2 wkssplint @ 90 degrees flexion x 2 wks

Other fx’s are managed with ORIF or percutaneous Other fx’s are managed with ORIF or percutaneous pinning & early motion post-operativelypinning & early motion post-operatively

Olecranon FracturesOlecranon Fractures

Olecranon FracturesOlecranon Fractures

Distal Humerus FractureDistal Humerus FractureSupracondylar fx’sSupracondylar fx’s of the Humerus: of the Humerus:– Characterized by dissociation b/t diaphysis & condyles of Characterized by dissociation b/t diaphysis & condyles of

distal humerus, frequently extended distally & involves distal humerus, frequently extended distally & involves articular surfacearticular surface

– Caused by FOOSH or direct blowCaused by FOOSH or direct blow– PE:PE:

+ deformity, instability, crepitus+ deformity, instability, crepitus

– XR:XR:AP/lat/obliqAP/lat/obliq

– Management:Management:Initial: alignment, immobilization, ice, long arm splintInitial: alignment, immobilization, ice, long arm splint

Definitive: ORIF, early motionDefinitive: ORIF, early motion

(Other fx’s: transcondylar, medial condyle, lateral (Other fx’s: transcondylar, medial condyle, lateral condyle)condyle)

The Wrist-Eight Carpal BonesThe Wrist-Eight Carpal Bones

SSome ome LLovers overs TTry ry PPositions ositions TThat hat TThey hey CCannot annot HHandleandle

Proximal / Distal row from radial to ulnar positionProximal / Distal row from radial to ulnar position

SScaphoidcaphoid,,LLunateunate,,TTriquetrumriquetrum,,PPisiformisiform,,

TTrapeziumrapezium,,TTrapezoidrapezoid,,CCapitateapitate,,HHamateamate

+ Radius and Ulna

Movements at the wristMovements at the wrist

Radial deviation (abduction)Radial deviation (abduction)

Ulnar deviation (adduction)Ulnar deviation (adduction)

FlexionFlexion

ExtensionExtension

SupinationSupination

PronationPronation

Combination of all of the aboveCombination of all of the above

Wrist DislocationsWrist DislocationsPerilunate, and Lunate dislocations are Perilunate, and Lunate dislocations are variations of the same injury variations of the same injury – Caused by hyperextension of the wrist (FOOSH)Caused by hyperextension of the wrist (FOOSH)

Exam:Exam:– Note areas of ecchymosis, active ROM, Note areas of ecchymosis, active ROM,

neurovascular statusneurovascular status– When dislocated, wrist appears shortened with a When dislocated, wrist appears shortened with a

fullness over the dorsum or in the carpal tunnelfullness over the dorsum or in the carpal tunnel– Any movement produces painAny movement produces pain– Swelling varies from barely perceptible to significant Swelling varies from barely perceptible to significant

Wrist DislocationsWrist DislocationsXR:XR:– Minimum 4 views: AP neutral, AP ulnar deviation, Minimum 4 views: AP neutral, AP ulnar deviation,

oblique, lateraloblique, lateral

Tx:Tx:– Reduce ASAP to minimize risk of median nerve Reduce ASAP to minimize risk of median nerve

injuryinjury– Axillary block or IV regional block provide adequate Axillary block or IV regional block provide adequate

muscular relaxation.muscular relaxation.– Apply traction for 5-10 min using finger trapsApply traction for 5-10 min using finger traps– Reduce & place in thumb spica plaster splint with Reduce & place in thumb spica plaster splint with

wrist in neutral or slight palmar flexionwrist in neutral or slight palmar flexion– Post reduction films are requiredPost reduction films are required– May Require surgery for adequate reductionMay Require surgery for adequate reduction

Perilunate dislocation Perilunate dislocation

Lunate dislocationLunate dislocation

Distal Forearm FracturesDistal Forearm Fractures1. Extension fractures: 1. Extension fractures:

Colles FractureColles Fracture– Fx distal radius with dorsal Fx distal radius with dorsal

angulation of distal fragment and angulation of distal fragment and associated fx of the ulnar styloidassociated fx of the ulnar styloid

– Usually Usually 2* to FOOSH2* to FOOSH– Exam:Exam:

swelling wrist, decreased ROM swelling wrist, decreased ROM secondary to painsecondary to pain

– XR:XR:AP/true lateral/obliq- radius will be AP/true lateral/obliq- radius will be shortenedshortened

Colles fxColles fx

Colles’ fxColles’ fx

Distal Forearm Fractures (cont)Distal Forearm Fractures (cont)Colles Fx (cont)Colles Fx (cont)– Tx:Tx:

Hang in finger trapsHang in finger trapsHematoma block: Hematoma block:

– Using an 18 gauge needle & 20cc syringe with 10cc 1% Using an 18 gauge needle & 20cc syringe with 10cc 1% lidocaine, enter fx site & aspirate hematoma (blood will flow into lidocaine, enter fx site & aspirate hematoma (blood will flow into syringe)syringe)

– After aspirating hematoma, inject lidocaine into fx siteAfter aspirating hematoma, inject lidocaine into fx site

Wait several minutes until pain is decreased & reduce fxWait several minutes until pain is decreased & reduce fxPlace in Place in long arm cast (LAC) with wrist @ 20-30 degrees long arm cast (LAC) with wrist @ 20-30 degrees of flexion & ulnar deviationof flexion & ulnar deviation

– Post reduction films are necessaryPost reduction films are necessary– Ice, elevate above level of heart, NSAID’s, Ice, elevate above level of heart, NSAID’s,

analgesiaanalgesia

Distal Forearm Fractures (cont)Distal Forearm Fractures (cont)2. Non-displaced Distal Radius Fx’s2. Non-displaced Distal Radius Fx’s– Require short arm cast (SAC) in neutral, ice, elevation, Require short arm cast (SAC) in neutral, ice, elevation,

NSAIDS, analgesiaNSAIDS, analgesia

3. Other common fx’s:3. Other common fx’s:– Smith’s fxSmith’s fx

Reverse Colles fxReverse Colles fxFracture of the distal radius with palmar (volar) displacement of the Fracture of the distal radius with palmar (volar) displacement of the distal fragment.distal fragment.

– Die Punch FxDie Punch FxIntra-articular distal radius fx with impaction of the dorsal aspect of Intra-articular distal radius fx with impaction of the dorsal aspect of the lunate fossathe lunate fossa

– Barton’s FxBarton’s FxDisplaced intra-articular lip fx of the distal radius Displaced intra-articular lip fx of the distal radius May be assoc with carpal subluxationMay be assoc with carpal subluxationMay be dorsal or volar configurationMay be dorsal or volar configurationExtends into radio-carpal jointExtends into radio-carpal joint

Smith’s fxSmith’s fx

Smith’s FxSmith’s Fx

Scaphoid FracturesScaphoid FracturesMC fx’d carpal boneMC fx’d carpal bone

There is There is no direct blood supply to the proximal no direct blood supply to the proximal portion of the scaphoidportion of the scaphoid

Therefore, scaphoid fx’s have a tendency to Therefore, scaphoid fx’s have a tendency to develop develop delayed union or avascular necrosisdelayed union or avascular necrosis

Remember the more proximal the fx line is in Remember the more proximal the fx line is in the scaphoid injuries, the greater the likelyhood the scaphoid injuries, the greater the likelyhood of avascular necrosisof avascular necrosis

Mechanism of injuryMechanism of injury– Forceful hyperextension of the wristForceful hyperextension of the wrist

Scaphoid FracturesScaphoid FracturesExam: Exam: + snuffbox tenderness,+ snuffbox tenderness, radial deviation of wrist will probably elicit painradial deviation of wrist will probably elicit pain

XR:XR:– Obtain AP/lat/obliq/scaphoid viewsObtain AP/lat/obliq/scaphoid views– Initial plain xray may not demonstrate fxInitial plain xray may not demonstrate fx for up to 4 wks for up to 4 wks– If xrays are still negative at 10-14 days & pt is symptomatic, If xrays are still negative at 10-14 days & pt is symptomatic,

obtain bone scan for definitive diagnosisobtain bone scan for definitive diagnosis– A bone scan will show an increase in uptake in fracture areaA bone scan will show an increase in uptake in fracture area

Tx:Tx:– Initially in ER:Initially in ER:

Thumb spica (*always tx snuffbox tenderness, even if xr neg)Thumb spica (*always tx snuffbox tenderness, even if xr neg)

– Definitive: Definitive: Long arm thumb spica castLong arm thumb spica cast x 4-8 wks. x 4-8 wks.If scaphoid is displaced, may require ORIFIf scaphoid is displaced, may require ORIF

A. ThumbA. ThumbB. IndexB. IndexC. Middle fingerC. Middle fingerD. Ring fingerD. Ring fingerE. Little fingerI-V. Metacarpal E. Little fingerI-V. Metacarpal bones1,4. Distal phalanxbones1,4. Distal phalanx2. Middle phalanx2. Middle phalanx3,5. Proximal phalanx3,5. Proximal phalanx6. Sesamoid bones6. Sesamoid bones7. Distal interphalangeal joint 7. Distal interphalangeal joint (DIP)(DIP)8. Proximal interphalangeal 8. Proximal interphalangeal joint (PIP)joint (PIP)9. Metacarpophalangeal joint 9. Metacarpophalangeal joint (V.)(V.)10. Carpometacarpal joints10. Carpometacarpal joints11. Trapezium11. Trapezium12. Trapezoid12. Trapezoid13. Capitate13. Capitate14. Hamate14. Hamate15. Scaphoid15. Scaphoid16. Lunate16. Lunate17. Triquetrum17. Triquetrum18. Pisiform18. Pisiform19. Radius19. Radius20. Ulna20. Ulna

Game Keeper’s ThumbGame Keeper’s ThumbSkier’s ThumbSkier’s Thumb

Injury to the Injury to the ulnar collateral ligamentulnar collateral ligament of the MCP joint of the MCP joint of the thumbof the thumb

Destroys joint stabilityDestroys joint stability

Impairs ability to pinchImpairs ability to pinch

Evaluation:Evaluation:

Stress ulnar aspect of the MCP joint by forcing thumb Stress ulnar aspect of the MCP joint by forcing thumb into radial abduction into radial abduction – If there is <15 degrees of side to side difference (one thumb If there is <15 degrees of side to side difference (one thumb

compared to the other) or an opening > 45 degrees at the compared to the other) or an opening > 45 degrees at the ulnar aspect of the MCP joint, surgical repair is requiredulnar aspect of the MCP joint, surgical repair is required

– Closed tx with a thumb spica cast or splint with the thumb Closed tx with a thumb spica cast or splint with the thumb slightly adducted may allow for healing of an incomplete tearslightly adducted may allow for healing of an incomplete tear

Distal Phalangeal FracturesDistal Phalangeal Fractures1. Closed:1. Closed:– Splint, Ice, AnalgesiaSplint, Ice, Analgesia

2. Open:2. Open:– Digital block c 1% lido local anesth.Digital block c 1% lido local anesth.– IrrigateIrrigate– ? ? RongeurRongeur– Sterile repair (suturing) of nailbed, place nail as Sterile repair (suturing) of nailbed, place nail as

biological dressingbiological dressing– Xeroform gauze (betadine/petroleum imbedded Xeroform gauze (betadine/petroleum imbedded

gauze) & sterile gauze dressinggauze) & sterile gauze dressing– SplintSplint– AntibioticsAntibiotics

Middle & Proximal Phalanx Middle & Proximal Phalanx FracturesFractures

Stable, non-displacedStable, non-displaced, impacted, transverse , impacted, transverse fx’s with no rotational deformity of the finger fx’s with no rotational deformity of the finger may be either may be either buddy taped or splintedbuddy taped or splinted with mcp with mcp joints flexed @ 50 degrees & PIP joints flexed joints flexed @ 50 degrees & PIP joints flexed @ 15-20 degrees@ 15-20 degreesFx’s with Fx’s with rotational deformitiesrotational deformities may require may require closed or closed or ORIF ORIF & casting/splinting& casting/splintingUnstable fx’s may require casting or Unstable fx’s may require casting or percutaneous pinning with Kirschner (K) wirespercutaneous pinning with Kirschner (K) wires– More recently these fx’s are being internally fixed More recently these fx’s are being internally fixed

with plates & screws from small fragment setswith plates & screws from small fragment sets

Finger dislocationFinger dislocation

ReduceReduce

SplintSplint

Metacarpal Neck FracturesMetacarpal Neck Fractures

Most frequently occur at the 5Most frequently occur at the 5thth metacarpal metacarpal ((Boxer’s fxBoxer’s fx) as a result of a direct blow ) as a result of a direct blow delivered to the hand or by the hand to a solid delivered to the hand or by the hand to a solid (animate or inanimate) object while the hand is (animate or inanimate) object while the hand is held in a fist held in a fist

Other Metacarpal Fx’sOther Metacarpal Fx’s

Bennett’sBennett’s

Rolando’sRolando’s

Lower ExtremitiesLower Extremities

Second Second PartPart

Knee Knee Standard Xray projections:Standard Xray projections:– AP – eval.joint space narrowing / calcificationsAP – eval.joint space narrowing / calcifications– Lateral –eval.Patella / effusionsLateral –eval.Patella / effusions

Special viewsSpecial views– Sunrise / merchant viewSunrise / merchant view

Tangential / knee flexed/from top-downTangential / knee flexed/from top-down

– Tunnel view Tunnel view Knee more flexed, looking through the “tunnel Knee more flexed, looking through the “tunnel created by the femoral condylescreated by the femoral condyles

KneeKnee

Most common reasons to order Knee Most common reasons to order Knee

X rays are:X rays are:

- trauma- trauma

- DJD ( X rays findings)- DJD ( X rays findings)

MRI – soft tissuesMRI – soft tissues

- tendons, ligaments, menisci, and - tendons, ligaments, menisci, and cartilagecartilage

KneeKnee

The KneeThe Knee

Ligaments:Ligaments:– Anterior Cruciate Ligament (ACL)Anterior Cruciate Ligament (ACL)– Posterior Cruciate Ligament (PCL)Posterior Cruciate Ligament (PCL)– Medial Collateral Ligament (MCL)Medial Collateral Ligament (MCL)– Lateral Collateral Ligament (LCL)Lateral Collateral Ligament (LCL)

Knee Knee

Knee effusion:Knee effusion:– Best seen on Lateral viewBest seen on Lateral view– Superior to PatellaSuperior to Patella– Anterior to distal femurAnterior to distal femur– Water or blood Water or blood – Same density as muscleSame density as muscle– Look for anterior displacement of fat lineLook for anterior displacement of fat line– Clinical examination superior to X ray Clinical examination superior to X ray

Knee soft tissue injuriesKnee soft tissue injuries

Most common:Most common:– Cruciate ligaments: Xrays NL. Dx made on Cruciate ligaments: Xrays NL. Dx made on

clinicals clinicals – and the menisci : plain film shows degree of and the menisci : plain film shows degree of

joint space narrowing and possible loose body joint space narrowing and possible loose body within the jointwithin the joint

MRI only if PE inconclusiveMRI only if PE inconclusive

ACL- originates in front of the intercondylar ACL- originates in front of the intercondylar eminence of the tibia and inserts on the eminence of the tibia and inserts on the posteromedial aspect of the lateral femoral posteromedial aspect of the lateral femoral condyle.condyle.– Lateral Lateral medial medial

The The ACL prevents anteriorACL prevents anterior translation of the tibiatranslation of the tibia

PCL-Originates on the medial femoral condyle PCL-Originates on the medial femoral condyle and inserts on the tibia.and inserts on the tibia.– Medial Medial lateral lateral

The The PCL prevents PCL prevents

posterior translation posterior translation

of the tibiaof the tibia

Medial Collateral LigamentMedial Collateral Ligament(MCL)(MCL)

Originates on the medial femoral Originates on the medial femoral epicondyle and inserts on the proximal epicondyle and inserts on the proximal tibiatibia

The MCL The MCL

prevents prevents

valgus angulationvalgus angulation

of the kneeof the knee

Lateral Collateral LigamentLateral Collateral Ligament(LCL)(LCL)

Originates on the lateral femoral Originates on the lateral femoral epicondyle and inserts on the lateral epicondyle and inserts on the lateral aspect of the fibular head.aspect of the fibular head.

It It prevents varus prevents varus

angulation of the kneeangulation of the knee

MenisciMenisciCrescent shaped fibrocartilagenous structures that are Crescent shaped fibrocartilagenous structures that are triangular in cross section.triangular in cross section.Only the peripheral 20-30% of the menisci are Only the peripheral 20-30% of the menisci are vascularized vascularized These structures deepen the articular surface of the These structures deepen the articular surface of the tibial plateau adding stability to the jointtibial plateau adding stability to the joint

Meniscal TearMeniscal TearMost Common injury to the knee requiring Most Common injury to the knee requiring surgerysurgery

Medial meniscal tears occur 3x more frequently Medial meniscal tears occur 3x more frequently than lateral meniscal tearsthan lateral meniscal tears

From acute trauma or chronic long term wear From acute trauma or chronic long term wear and tearand tear

Locked knee requires urgent interventionLocked knee requires urgent intervention

Meniscal Tear DiagnosisMeniscal Tear Diagnosis

– History: History: Locking, clicking soundLocking, clicking sound

catching episodes / giving way episodescatching episodes / giving way episodes

pain with squatting / Swellingpain with squatting / Swelling

– Physical Exam:Physical Exam:+ effusion+ effusion

+ joint line tenderness+ joint line tenderness

+ McMurray’s sign+ McMurray’s sign

Meniscal TearMeniscal TearTreatment:Treatment:– Meniscal repair may be achieved arthroscopically Meniscal repair may be achieved arthroscopically

by suturing the torn meniscusby suturing the torn meniscusThis may be an option if tear occurs in an area with blood This may be an option if tear occurs in an area with blood supplysupply

– Partial meniscectomyPartial meniscectomyArthroscopic removal of the torn meniscusArthroscopic removal of the torn meniscus

Ligament SprainsLigament Sprains

Ligament sprainsLigament sprains

Medial Collateral Ligament Medial Collateral Ligament (MCL)(MCL)SprainSprain

Caused by Caused by valgus force to kneevalgus force to kneeDiagnosis:Diagnosis:– + tenderness along MCL (Grade I-III)+ tenderness along MCL (Grade I-III)– + opening of medial joint line with valgus stress when knee + opening of medial joint line with valgus stress when knee

is @ 30 degrees of flexion (Grades II-III)is @ 30 degrees of flexion (Grades II-III)– (Posterior Cruciate Ligament is most responsible for medial-(Posterior Cruciate Ligament is most responsible for medial-

lateral stability when knee is fully extended)lateral stability when knee is fully extended)

Tx:Tx:– IceIce– NSAIDSNSAIDS– Physical TherapyPhysical Therapy– Grade III sprains may require surgical repairGrade III sprains may require surgical repair

Lateral Collateral Ligament (LCL) Lateral Collateral Ligament (LCL) SprainSprain

Caused by Caused by varus force to kneevarus force to knee UncommonUncommonDx:Dx:– + tenderness along LCL (Grade I-III)+ tenderness along LCL (Grade I-III)– + opening of lateral joint line with varus stress + opening of lateral joint line with varus stress

when knee is @ 30 degrees of flexionwhen knee is @ 30 degrees of flexion

Tx:Tx:– Non-operative:Non-operative:

IceIceNSAIDSNSAIDSPhysical therapyPhysical therapy

Anterior Cruciate Ligament (ACL) Anterior Cruciate Ligament (ACL) SprainsSprains

Caused by Caused by twisting of knee while twisting of knee while foot is firmly planted on groundfoot is firmly planted on ground

Hx:Hx:– Patient Patient hears a “pop”hears a “pop” feels a tear and feels a tear and

acute pain in kneeacute pain in knee– Knee may feel unstable with weight Knee may feel unstable with weight

bearingbearing– Acute swelling at time of injuryAcute swelling at time of injury

Anterior Cruciate Ligament (ACL) Anterior Cruciate Ligament (ACL) SprainsSprains

Dx:Dx:– + Lachman+ Lachman (20-30 degrees flexion, pull tibia anteriorly) (20-30 degrees flexion, pull tibia anteriorly)– + anterior drawer+ anterior drawer (90 degrees) (90 degrees)– + pivot shift with anterolateral instability+ pivot shift with anterolateral instability– Arthrocentesis reveals hemarthrosisArthrocentesis reveals hemarthrosis– MRI >90% accurateMRI >90% accurate

Tx:Tx:– Physical therapy (pre/post op)Physical therapy (pre/post op)– Open vs. Arthroscopic surgical reconstruction with patella Open vs. Arthroscopic surgical reconstruction with patella

tendon or hamstring tendon autograft; allograft (cadaver); tendon or hamstring tendon autograft; allograft (cadaver); xenograft (another animal)xenograft (another animal)

– CPM (continuous passive motion machine) and hinged CPM (continuous passive motion machine) and hinged knee brace post-opknee brace post-op

– If stable = no surgery nec. If stable = no surgery nec.

ACL tearACL tear

Posterior Cruciate Ligament Posterior Cruciate Ligament (PCL) Sprain(PCL) Sprain

Caused by Caused by hyperextension of knee or direct hyperextension of knee or direct blow to anterior aspect of flexed knee blow to anterior aspect of flexed knee (Dashboard)(Dashboard)Dx:Dx:– + posterior drawer+ posterior drawer– MRI >90% accurateMRI >90% accurate

Tx:Tx:– Physical therapyPhysical therapy– Surgical reconstruction in patients who have Surgical reconstruction in patients who have

high demand knees (athletes) and severe high demand knees (athletes) and severe instabilityinstability

Unhappy TriadUnhappy Triad

This is the term given to an injury where the This is the term given to an injury where the ACL, MCL and Medial Meniscus are all ACL, MCL and Medial Meniscus are all three torn.  three torn. 

The mechanism for this injury is usually a The mechanism for this injury is usually a lateral blow to the knee with the foot fixed.  lateral blow to the knee with the foot fixed. 

1. ACL tear1. ACL tear

2. MCL tear2. MCL tear

3. Medial meniscus tear3. Medial meniscus tear

Patellar Tendon RupturePatellar Tendon Rupture

Most frequently in patient <40 y/oMost frequently in patient <40 y/o

Exam:Exam:– Patient cannot actively extend kneePatient cannot actively extend knee– Palpable defect inferior to patellaPalpable defect inferior to patella

Xray:Xray:– + patella alta+ patella alta

Tx:Tx:– Surgical repairSurgical repair– Weight bear as tolerated (wbat) with knee in Weight bear as tolerated (wbat) with knee in

extensionextension

Patella tendon Patella tendon rupturerupture– Notice superior Notice superior

appearing patellaappearing patella

Normal Knee

Patella Dislocation/ SubluxationPatella Dislocation/ Subluxation

Lateral displacementLateral displacement of patella of patellaAcute vs. recurrentAcute vs. recurrentReduction occurs with knee in extensionReduction occurs with knee in extension+ patella apprehension test+ patella apprehension testTx:Tx:– mobilization and strengthening exercisesmobilization and strengthening exercises– Vs. Vs. – Immobilization in cylinder cast x 6 wks Immobilization in cylinder cast x 6 wks – Vs.Vs.– Surgical repairSurgical repair

Patellar fractures Patellar fractures

Direct blow to patella – fallDirect blow to patella – fall

Dark lines across the boneDark lines across the bone

Sharp corners and edgesSharp corners and edges

Repair by fixation pins and wireRepair by fixation pins and wire

Patellar fracturePatellar fracture

Chronic Knee PainChronic Knee Pain

DJD – OA vs RA -DJD – OA vs RA -

PEPE– Decreased ROMDecreased ROM– No systemic symptoms No systemic symptoms – Plain radiographs for initial workup (standing)Plain radiographs for initial workup (standing)

X ray findingsX ray findings– joint space narrowing (Medial common)joint space narrowing (Medial common)– Spurs Spurs – Sclerotic bony marginsSclerotic bony margins

Loose body: disruption of cartilage , single Loose body: disruption of cartilage , single broken piece.broken piece.

If multiple pieces – synovial If multiple pieces – synovial chondromatosis chondromatosis

Chondrocalcinosis : calcification within Chondrocalcinosis : calcification within articular cartilage of the joint (DJD, articular cartilage of the joint (DJD, hypercalcemia, pseudogout) linear hypercalcemia, pseudogout) linear calcificationscalcifications

Knee ReplacementKnee ReplacementIndicated for severe DJDIndicated for severe DJD– Femoral condylar componentFemoral condylar component– Proximal tibial componentProximal tibial component– Patellar componentPatellar component

AP- may look like components are not AP- may look like components are not touching – plastic component not seen on touching – plastic component not seen on XrayXray

Infection and looseningInfection and loosening

Both look as lucent space around screws Both look as lucent space around screws and base of the implantand base of the implant

FootFootBones of the foot:Bones of the foot:– 7 tarsals7 tarsals

TalusTalusCalcaneusCalcaneusNavicularNavicularMedial CuneiformMedial CuneiformIntermediate CuneiformIntermediate CuneiformLateral CuneiformLateral CuneiformCuboidCuboid

– 5 metatarsals5 metatarsals““rays of the foot”rays of the foot”

– 14 phalanges14 phalanges

Plantar FasciitisPlantar FasciitisPlantar fasciitis is the #1 most common foot Plantar fasciitis is the #1 most common foot problem. problem. It is caused by activity, overuse and aging. It is caused by activity, overuse and aging. Plantar fasciitis is an inflammation due to Plantar fasciitis is an inflammation due to repeated overstretching of the plantar fascia repeated overstretching of the plantar fascia ligament (fat pad of the foot), usually at the ligament (fat pad of the foot), usually at the point where the fascia is attached to the point where the fascia is attached to the calcaneus. calcaneus. Pain is most severe in the morning and Pain is most severe in the morning and stepping down onto foot, decreases as day stepping down onto foot, decreases as day goes ongoes on

Plantar FasciitisPlantar FasciitisContributing factors are: Contributing factors are: – flat flat (pronated) feet (pronated) feet – high archeshigh arches (supinated feet) (supinated feet) – increasing age increasing age – sudden weight increase sudden weight increase – sudden increase in activity level sudden increase in activity level – running in sandrunning in sand – hereditary factors hereditary factors

Xray: May reveal Xray: May reveal bony spurbony spur at same site at same site

Plantar FasciitisPlantar Fasciitis

Tx:Tx:– Achilles stretching (tennis ball)Achilles stretching (tennis ball)– massagemassage– Rest from activitiesRest from activities– NSAIDSNSAIDS– Shock absorbing heel cupsShock absorbing heel cups– Ankle orthosis (AFO) for recalcitrant casesAnkle orthosis (AFO) for recalcitrant cases– Avoid cortisone injectionsAvoid cortisone injections

Hallux ValgusHallux ValgusMost common deformity of the foot Most common deformity of the foot Results in excessive valgus angulation of the big toe Results in excessive valgus angulation of the big toe Splaying of the forefoot with varus angulation of the first Splaying of the forefoot with varus angulation of the first metatarsal predisposes metatarsal predisposes The anatomical deformity consists of: The anatomical deformity consists of: – Increased forefoot width Increased forefoot width – Lateral deviation of the hallux Lateral deviation of the hallux – Prominence of the first metatarsal head Prominence of the first metatarsal head

Clinical featuresClinical features– More common in women More common in women – Often bilateral Often bilateral

Symptoms result from Symptoms result from – A bursa over metatarsal head = A bursa over metatarsal head = bunionbunion – Osteoarthritis of the first MTPJ Osteoarthritis of the first MTPJ

Hallux ValgusHallux ValgusXray:Xray:– Bilateral weight bearing AP/ lateral/ oblique footBilateral weight bearing AP/ lateral/ oblique foot

Initial Tx:Initial Tx:– Shoewear education/ modification (sneakers)Shoewear education/ modification (sneakers)

Surgical Tx:Surgical Tx:– Distal metatarsal osteotomy +/- internal fixation for Distal metatarsal osteotomy +/- internal fixation for

mild deformitymild deformity– 11stst tarsal metatarsal arthrodesis (fusion) for tarsal metatarsal arthrodesis (fusion) for

hypermobile 1hypermobile 1stst ray ray

Lisfranc InjuryLisfranc InjuryFracture and lateral dislocation of 2Fracture and lateral dislocation of 2ndnd, 3, 3rdrd,4,4thth and 5 and 5thth metatarsals relative to the tarsal bonesmetatarsals relative to the tarsal bonesMOI: falling out of a saddle, foot caught on stirrup, or MOI: falling out of a saddle, foot caught on stirrup, or stepping into a hole with twisting of the footstepping into a hole with twisting of the footExam:Exam:– + tenderness at Lisfranc joint + tenderness at Lisfranc joint – + swelling dorsally+ swelling dorsally

XR:XR:– AP/ lateral/ oblique foot (weight bearing when possible): AP/ lateral/ oblique foot (weight bearing when possible): – May reveal widening at jointMay reveal widening at joint

Tx:Tx:– Reduced & treated with screw fixationReduced & treated with screw fixation– NWB x 6-8 wksNWB x 6-8 wks

Jones Fracture/Dancers fractureJones Fracture/Dancers fractureTransverse fracture of the 5Transverse fracture of the 5thth metatarsal at the metatarsal at the junction of the proximal metaphysis & diaphysisjunction of the proximal metaphysis & diaphysisPE:PE:– + tenderness lateral aspect of foot+ tenderness lateral aspect of foot– + swelling + swelling – +/- ecchymosis+/- ecchymosis

XR:XR:– AP/ lat/ obliqAP/ lat/ obliq

Tx:Tx:– Short leg cast (SLC) Short leg cast (SLC) – Non-wt bearingNon-wt bearing (NWB) x 6wks (NWB) x 6wks

Frequently fail to heal when treated non-operatively, Frequently fail to heal when treated non-operatively, especially in smokersespecially in smokersSurg:Surg:– ORIFORIF

Jones fxJones fx

Avulsion Fracture of the base of the Avulsion Fracture of the base of the 55thth Metatarsal Metatarsal

Pseudo-Jones fxPseudo-Jones fx/ dancer fx/ tennis fx/ dancer fx/ tennis fxOccurs when the insertion of the peroneus brevis is Occurs when the insertion of the peroneus brevis is avulsed during forced inversion of the forefootavulsed during forced inversion of the forefootExam:Exam:– + tenderness+ tenderness– + swelling at base of 5+ swelling at base of 5thth metatarsal metatarsal– +/- ecchymosis+/- ecchymosis

XR:XR:– AP/lat/obliqAP/lat/obliq

Tx:Tx:– Short leg walking cast (SLWC) x 6 wksShort leg walking cast (SLWC) x 6 wks

Pseudo-Jones FracturePseudo-Jones FractureDancer FractureDancer FractureTennis FractureTennis Fracture

Avulsion FractureAvulsion Fracture

Pseudo-Jones FracturePseudo-Jones Fracture

Comminuted Fracture of Comminuted Fracture of proximal and/ or distal phalanx proximal and/ or distal phalanx

of great toeof great toeXR:XR:– AP/lat/obliqAP/lat/obliq

Tx:Tx:– SplintSplint– Hard sole shoeHard sole shoe– IceIce– Buddy tapeBuddy tape

Fractures of phalanges of lesser Fractures of phalanges of lesser toestoes

XR:XR:– AP/lat/obliqAP/lat/obliq

Tx:Tx:– Buddy tapeBuddy tape– Ice Ice – NSAIDSNSAIDS

March FractureMarch Fracture

Stress fracture usually of the middle of the shaft Stress fracture usually of the middle of the shaft of the 3of the 3rdrd metatarsal (or 4 metatarsal (or 4thth))

History of having gone on long walk/march with History of having gone on long walk/march with no clear h/o traumano clear h/o trauma

Also seen in females with eating/exercising Also seen in females with eating/exercising disordersdisorders

Exam:Exam:– + tenderness midshaft of the involved metatarsal+ tenderness midshaft of the involved metatarsal– Pain with increased flexion or extension of toesPain with increased flexion or extension of toes– Pain subsides with restPain subsides with rest

March FractureMarch Fracture

Initial XR:Initial XR:– AP/lat/obliq weight bearing foot will be AP/lat/obliq weight bearing foot will be

negativenegative

Follow up XR:Follow up XR:– In 2 wks will show callus formationIn 2 wks will show callus formation

Tx:Tx:– Symptomatically with crutches or if patient’s Symptomatically with crutches or if patient’s

occupation requires prolonged standing or occupation requires prolonged standing or ambulationambulation

– SLWC x 3-4 wksSLWC x 3-4 wks

Stress fxStress fx

Calcaneus FracturesCalcaneus FracturesMay be May be intraarticular or extraarticularintraarticular or extraarticular

h/o fall or twisting injury & pain localized to hindfoot h/o fall or twisting injury & pain localized to hindfoot (tarsal)(tarsal)

XR:XR:– AP/lat/obliq/ axial heel/ Broden’s view (lateral xray with foot AP/lat/obliq/ axial heel/ Broden’s view (lateral xray with foot

passively dorsiflexed/ supinated & internally rotated)passively dorsiflexed/ supinated & internally rotated)

Should have CT scan to review extent of fxShould have CT scan to review extent of fx

Also do Xray of Lumbar spine due to associated fx’sAlso do Xray of Lumbar spine due to associated fx’s

Initial management:Initial management:– SplintSplint– IceIce– ElevationElevation

Calcaneus FractureCalcaneus FractureTx:Tx:– Non-displaced intraarticular fx= NWB 4-6 wksNon-displaced intraarticular fx= NWB 4-6 wks– Displaced intraarticular fx= ORIF, NWB x 6-8 wks, Displaced intraarticular fx= ORIF, NWB x 6-8 wks,

early motionearly motion– Minimally displaced tuberosity fracture= NWB 3-6 Minimally displaced tuberosity fracture= NWB 3-6

wkswks– Displaced tuberosity fx= internal fixation, NWB 4-Displaced tuberosity fx= internal fixation, NWB 4-

6wks6wks– Sustentaculum tali= SLWC x 4-6 wksSustentaculum tali= SLWC x 4-6 wks– Non-displaced anterior process fx= SLWC x 4-6 Non-displaced anterior process fx= SLWC x 4-6

wkswks– Displaced anterior process fx = ORIFDisplaced anterior process fx = ORIF

The AnkleThe Ankle

BonesBones– TibiaTibia– FibulaFibula– TalusTalus

Obtain AP/lat/Obtain AP/lat/obliqobliq to r/o fractureto r/o fracture

Anterior fat line Anterior fat line displacement with displacement with effusion (Lateral effusion (Lateral view)view)

Ankle sprainsAnkle sprainsInversion injury= MC mechanism of injury / injures Inversion injury= MC mechanism of injury / injures lateral structures of anklelateral structures of ankleMC ligament sprained= MC ligament sprained= – 1. 1. Anterior talofibular ligament (front) - tears firstAnterior talofibular ligament (front) - tears first – 2. Posterior talofibular ligament (back) - tears second 2. Posterior talofibular ligament (back) - tears second – 3. Calcaneofibular ligament (middle) - tears last 3. Calcaneofibular ligament (middle) - tears last

Tx:Tx:– Ice x 20min several x/dayIce x 20min several x/day– ElevationElevation– NSAIDSNSAIDS– WBAT c crutches prnWBAT c crutches prn– Early ROMEarly ROM– strengtheningstrengthening

Ankle fracturesAnkle fractures

Most common:Most common:

Medial or Lateral malleolusMedial or Lateral malleolus

Severe trauma – trimalleolar fractureSevere trauma – trimalleolar fracture– When severe associated ligament damage When severe associated ligament damage

and subluxation of distal tibia over the talusand subluxation of distal tibia over the talus

Stress views when NL Xray (standard) Stress views when NL Xray (standard) and high clinical suspicion of traumaand high clinical suspicion of trauma

Bi - Malleolar fractureBi - Malleolar fractureAnkle inversion injury:Ankle inversion injury:– Horizontal fibular fracture and oblique medial Horizontal fibular fracture and oblique medial

malleolus fracturemalleolus fracture

Ankle eversion fracture:Ankle eversion fracture:– Horizontal medial malleolus fracture with oblique Horizontal medial malleolus fracture with oblique

fibular fracturefibular fracture

Bimalleolar fracture-inversion injuryBimalleolar fracture-inversion injury

Foot FracturesFoot Fractures

Can involve any boneCan involve any bone

Talus fractures are rare - MVAccidentTalus fractures are rare - MVAccident

Calcaneous fracture hard to see in Calcaneous fracture hard to see in standard views – order calcaneal viewstandard views – order calcaneal view

Place foot on film and shooting down Place foot on film and shooting down along the back side of the anklealong the back side of the ankle

Achilles TendinitisAchilles TendinitisPain at achilles tendon, increased by running Pain at achilles tendon, increased by running decreased by restdecreased by restPain is often worse following activity, rather Pain is often worse following activity, rather than duringthan duringOften palpable thickening over tendon or Often palpable thickening over tendon or peritendinous tissuesperitendinous tissues

Achilles Tendon RuptureAchilles Tendon RuptureOccurs most commonly at narrowest portion of Occurs most commonly at narrowest portion of tendon approx. 2 inches superior to point of tendon approx. 2 inches superior to point of attachment to calcaneusattachment to calcaneus

Mechanisms of injury:Mechanisms of injury:

– 1. extra stretch applied to taut tendon1. extra stretch applied to taut tendon

– 2. forceful dorsiflexion with ankle in relaxed 2. forceful dorsiflexion with ankle in relaxed statestate

– 3. direct trauma to taut tendon3. direct trauma to taut tendon

Achilles Tendon RuptureAchilles Tendon Rupture

C/O acute pain in lower calf & difficulty C/O acute pain in lower calf & difficulty ambulatingambulating

+/- palpable defect or mass in post. calf +/- palpable defect or mass in post. calf

+ Thompson test+ Thompson test – squeeze calf, foot should plantarflex, if no squeeze calf, foot should plantarflex, if no

plantarflexion then achilles tendon is outplantarflexion then achilles tendon is out

Tx:Tx:– 1. surgical repair1. surgical repair– 2. equinus walking boot x 8 wks followed by 2.5 cm 2. equinus walking boot x 8 wks followed by 2.5 cm

heel for another 4 weeksheel for another 4 weeks

Tibial Shaft FracturesTibial Shaft Fractures

Mechanisms of injuryMechanisms of injury– 1. direct trauma: MVA, skiing, (boot top)1. direct trauma: MVA, skiing, (boot top)– 2. indirect trauma: assoc with rotary & compressive forces 2. indirect trauma: assoc with rotary & compressive forces

as from skiing or a fallas from skiing or a fall

Exam:Exam:– Pain, swelling, deformityPain, swelling, deformity

XR:XR:– AP/lateral tibia fibulaAP/lateral tibia fibula

Tibial Plateau FracturesTibial Plateau FracturesInvolve proximal articular surface of tibiaInvolve proximal articular surface of tibiaExam:Exam:– Pain localized to proximal tibia, +/- swellingPain localized to proximal tibia, +/- swelling

Imaging:Imaging:– AP, lateral kneeAP, lateral knee– CT scanCT scan

Tibial Plateau Fracture ClassificationTibial Plateau Fracture Classification

HipXray views

AP and “frog legs” (abducted)

Lateral views hard to interprete

Evaluate the relationship of femoral head to the acetabulum

Look for cortical discontinuities

Look at trabecular pattern

Hip dislocations

From M V AccidentsMost common posterior dislocation– On AP - head of femur located superiorly and laterally

displaced

Anterior dislocation: inferior and medialLook for associated fracture fragments from the acetabulum

Hip dislocationPosterior dislocation:Head of the femur superior and laterally located

Anterior dislocation:Head of femur located inferiorly and medially to the acetabulum

Hip fractures

90% of hip fracture either at:

Femoral neck - OsteoporoticUnable to walk after a fall

Little deformity

Intertrochanteric - post traumaticShorter leg in internal rotation

Stress frx dificult to detect in elderly

Nondisplaced frx better seen MRI

Bone scan ( may take several days to show)

Open Book fx

Intertrochanteric frx

Hip FxHip Fx

Hip fracture classifications most Hip fracture classifications most often are based on their anatomic often are based on their anatomic locations: head, neck, locations: head, neck, intertrochanteric, trochanteric, and intertrochanteric, trochanteric, and subtrochanteric subtrochanteric

Hip & Proximal Femur Fx’sHip & Proximal Femur Fx’sFemoral head fracturesFemoral head fractures – These usually are associated with hip dislocations. Superior femoral head These usually are associated with hip dislocations. Superior femoral head

fractures normally are associated with anterior dislocations, while inferior femoral fractures normally are associated with anterior dislocations, while inferior femoral head fractures are associated with posterior dislocations. head fractures are associated with posterior dislocations.

– Type 1 - Single fragment fracturesType 1 - Single fragment fractures– Type 2 - Comminuted fracturesType 2 - Comminuted fractures

Femoral neck fracturesFemoral neck fractures – Type 1 - Stress fractures or incomplete fracturesType 1 - Stress fractures or incomplete fractures– Type 2 - Impacted fracturesType 2 - Impacted fractures– Type 3 - Partially displaced fractures Type 3 - Partially displaced fractures – Type 4 - Completely displaced or comminuted fracturesType 4 - Completely displaced or comminuted fractures

Intertrochanteric fracturesIntertrochanteric fractures – Type 1 - Single fracture line; no displacement; considered stableType 1 - Single fracture line; no displacement; considered stable– Type 2 - Multiple fracture lines or comminution; displacement; unstable Type 2 - Multiple fracture lines or comminution; displacement; unstable

Trochanteric fracturesTrochanteric fractures – Type 1 - Nondisplaced fractures Type 1 - Nondisplaced fractures – Type 2 - Displaced fracture; greater than 1 mm displacement for greater Type 2 - Displaced fracture; greater than 1 mm displacement for greater

trochanteric fractures and greater than 2 mm displacement for lesser trochanteric trochanteric fractures and greater than 2 mm displacement for lesser trochanteric fractures fractures Subtrochanteric fracturesSubtrochanteric fractures

– Stable - Bony contact of medial and posterior femoral cortices Stable - Bony contact of medial and posterior femoral cortices – UnstableUnstable

Femoral HeadFemoral Head

Femoral NeckFemoral Neck

Intertrochanteric fxIntertrochanteric fx

Trochanteric fxTrochanteric fx

Hip & ProximalHip & Proximal Femur fx Femur fx

Leg shortened and Leg shortened and externally rotatedexternally rotated

Hip DislocationHip DislocationMC is posterior MC is posterior dislocationdislocation– Due to dashboardDue to dashboard

Aseptic necrosis hips

Xray changes

Flattening, irregularity, sclerosis of superior aspect femoral head(late)

Early findings on MRI/bone scan

Caused by trauma and chronic steroid use

Aseptic necrosis of the hips

Slipped Capital Epiphysis

Cause unknown Does not occur before age 9 yoOverweight teenage maleRadiographic dxThickened epiphyseal plateMedial displacement of the femoral head relative to the femoral neckLateral and frog leg views used for dx

Slipped Capital Epiphysis

Osgood - Schlatter disease

Traumatic tibial lesion in children

Avultion fracture of the anterior tibial tuberosity

Frequent in active boys paticipating in sports

Pain present

Age 10-15 yo

Heals with rest

Osgood - Schlatter disease

Legg-Perthes disease(aseptic necrosis of the femoral head)

Boys more than girls

Limp + pain + limited ROM of the hip

Irregularity , sclerosis and fragmentation of epiphysis

Resulting deformity with OA after a few decades

Legg-Perthes disease(aseptic necrosis

of the femoral head)