O S T E O A R T H R I T I S

KEY INFORMATION
Weight-bearing joints (knees, hips, spine)
Heberden (DIP) & Bouchard (PIP) nodes

ETIOLOGY / PATHO DIAGNOSIS

Loss of articular cartilage & joint degeneration Normal inflammatory markers

Risk factors ESR, CRP, RA, ANA

Obesity X-ray = ASYMMETRIC joint narrowing, osteophytes, &

Trauma subchondral bone sclerosis & cysts

Heavy labor

Elderly TREATMENT
Treatment = lifestyle, meds, injections, & surgery
Female
Lifestyle = weight loss, exercise, & assistive devices
FHx NSAIDs (topical & PO) = 1st line

Sports activities Oral = naproxen, ibuprofen, & diclofenac

Takes ~2 weeks to work
Pitching = shoulders & elbow
S/E = GI, renal & CV (naproxen if CV risk)

Football = knees, ankles & feet Topical = diclofenac sodium gel 1% & patch
Topical = better safety profile
Soccer = neck, hip, knees & talar joints
Takes ~2 weeks to work
S/E = rash, itching, or burning

SYMPTOMS & EXAM

Tramadol = mild narcotic with low abuse potential
Tylenol = no longer considered 1st line
Duloxetine = multiple joints & can’t use NSAIDs
Asymmetric joint pain = worse with ACTIVITY
Capsaicin (topical) = not for acute pain
AM stiffness <1 hour -> worsens during day Takes ~2 weeks to work

MC = small joints (wrist, MCP, PIP -> no DIP) S/E = local burning at site
Hyaluronic acid (injection) = symptomatic relief
Joints = hard & bony (no inflammatory signs!)
Steroid (injection) = temporary relief
Heberden (DIP) & Bouchard (PIP) nodes
Moderate to severe pain
↓ ROM Affecting one or a few joints

Crepitus Joint replacement = refractory to lifestyle & meds

*DON'T FORGET*: ASYMMETRIC JOINT PAIN

 O S T E O P O R O S I S
KEY INFORMATION
Resorption > formation
DEXA scan = best diagnostic test

ETIOLOGY / PATHO DIAGNOSIS

Loss of bone density -> mineral & matrix DEXA scan = best diagnostic test (hip & spine)
T-scores
Imbalance of bone resorption > formation
Normal = >-1.0
Osteopenia = precursor Osteopenia = -1.0 to -2.5
Types Osteoporosis = <-2.5
Primary Ca2+, phosphate & PTH = normal

Postmenopausal ( ↓ estrogen) Alk phos = normal

TSH = screen for hyperthyroidism
Elderly
Secondary
Hypogonadism
TREATMENT
CKD, DM, or hyperthyroidism
Cushing’s disease = ↑ cortisol Treatment = lifestyle & meds

↓ Ca2+ & vitamin D Lifestyle

Vitamin D (800) & Ca2+ (1200) supplements

Malignancy = skeletal cancer (myeloma)
Weight bearing exercise
Meds = heparin, phenytoin, lithium, &
levothyroxine Smoking cessation

Risk factors Fall prevention

Female Bisphosponates = 1st line -> inhibit osteoclasts

History of frailty fracture IV = zoledronic acid & ibandronate

Low BMI or BMD PO = alendronate, risedronate, & ibandronate

Steroid use S/E = flu-like symptoms, MSK pain, esophagitis, GI

Smoking & EtOH sx, osteonecrosis of the jaw

Take with water & stay upright for 30 min

SYMPTOMS & EXAM Calcitonin = last line -> weak effect on bone density

No treatment for osteopenia -> supportive care!

Pain = back, hip, knees, etc. Vitamin D (800) & Ca2+ (1200) supplements

Bone fractures = vertebrae (MC), hip, & radius Weight bearing exercise

Smoking cessation
Loss of vertebral height = spine compression
Fall prevention

*DON'T FORGET*: ELDERLY FEMALE

 LOW BACK PAIN
KEY INFORMATION
Resolves ~6 weeks
AVOID prolonged best rest

ETIOLOGY / PATHO DIAGNOSIS

X-ray = red flags!
Strained muscle or sprained ligament in back
Trauma
Something alters mechanics of lumbar area Malignancy
Concern for new cancer
Etiologies
Fever, chills, weight loss, night pain, etc.
Acute traumatic event Immunosuppression
Night pain
Repetitive micro-trauma
TTP on spinous processes (midline)
Risk factor = obesity Age >50
>4-6 weeks without improvement

SYMPTOMS & EXAM

TREATMENT
Worse with movement = spine ROM
Treatment = supportive & meds
Improves with rest Supportive = resume activity & BRIEF bed rest

Pain without moving = not good! (cancer??) Movement helps muscles repair!

AVOID prolonged bed rest

Delayed soreness/stiffness after event
Patient education = proper lifting techniques
Paraspinal muscle tenderness
Muscle tear -> scar tissue -> risk of reinjury

NORMAL neuro exam Likely to injure again because scar tissue is not

as flexible as native muscle tissue

NSAIDs = IV or IM if in severe pain before discharge

Scheduled pain meds often better than prn

Muscle relaxers

Flexeril = can make you tired (do not drive)

Baclofen = help control spasm

Valium (benzo) = ultimate muscle relaxer

Most resolve in ~6 weeks!

*DON'T FORGET*: RESOLVE IN ~6 WEEKS

 HERNIATED DISC
KEY INFORMATION
Unilateral pain
Pain RADIATING down leg

ETIOLOGY / PATHO DIAGNOSIS

Bulging disc into or though annulus fibrosus X-ray = loss of disc height & degenerative changes
Firm fibrous ring = annulus fibrosus (AF)
MRI = diagnostic test of choice
Tiny unmyelinated nerves in AF
Can get tear in AF & cause pain
Gelatinous core = nucleus pulposus (NP)
No nerves identified within NP
TREATMENT
Most discs herniate posterolaterally Treatment = supportive, steroids, injections, or surgery
PLL in the back which is strong
Supportive = PT, NSAIDs and muscle relaxers
ALL in the front which is strong
PT (Mckenzie method) = extension exercises
Bending forward = jelly in donut goes back
Can’t go straight back because of PLL NSAIDs or Tylenol = main thing in ER

Goes off to the sides! Muscle relaxers = nerve causing 2o muscle spasm
Etiologies Flexeril = can make you tired (do not drive)
Cervical = MC at C5-C6 & C6-C7
Valium (benzo) = ultimate muscle relaxer
Lumbar = MC at L5-S1 (also L4-L5)
Steroids (PO) = takes 48 hours so need pain meds 1st

SYMPTOMS & EXAM Help because of inflammation around nerve

Steroids (injection) = refractory to other therapy

RADICULOPATHY
Preferred over PO steroid b/c no systemic S/E
Back pain = unilateral & radiates down leg
(+) straight leg test Surgery = decompression or discectomy

(+) cross over test Decompression (laminectomy) = taking out lamina

L4 = anterior thigh pain (area around spinal nerve) to decompress
DTR = loss of knee jerk
Discectomy w/ fusion
Weakness of ankle dorsiflexion
Discectomy w/ replacement = more popular
L5 = lateral thigh/leg, hip & groin pain
DTR = none
Weakness of big toe extension
S1 = posterior leg & calf pain
DTR = loss of ankle jerk
Weakness of plantar flexion

*DON'T FORGET*: RADICULOPATHY

LUMBAR SPINAL STENOSIS
KEY INFORMATION
Unilateral OR bilateral pain
Narrowed spinal canal

ETIOLOGY / PATHO DIAGNOSIS

Narrowing spinal canal with nerve impingement MRI = diagnostic test of choice
Types
Degenerative disc disease (DDD)
Disc gets smaller because losing water TREATMENT
Losing height from DDD – so foramen is more
narrow (stenosed) Treatment = supportive and surgery

Degenerative joint disease (DJD) Supportive = pain control & physical therapy
Spondylosis = arthritis of back
Steroids (injection) = epidural or foraminal
Osteophytes & bone spurs
Compressing & stenosing foramen Delay need for surgery
Etiologies
Surgery = decompression laminectomy
Degenerative arthritis (DDD)
Spondylosis (DJD)
Post-surgical
Congenial
Trauma
Inflammation

SYMPTOMS & EXAM

RADICULOPATHY

Back pain = billateral or unilateral

Numbness & paresthesia’s -> radiates down leg

Worsens = extension or walking DOWNHILL

Improves = flexion or walking UPHILL

"shopping cart" = leaning forward on

shopping cart improves pain

*THINK ABOUT*: "SHOPPING CART" IMPROVES

 S P O N D Y L O L Y S I S
KEY INFORMATION
Pars interarticularis defect
MC = L5-S1

ETIOLOGY / PATHO DIAGNOSIS

X-ray = (LATERAL) = scottie dog deformity
Pars interarticularis defect
Scottie dog with “broken neck”
Stress fracture at pars interarticularis
Defect in pars interarticularis
Mechanism = repetitive hyperextension
Bone scan = more sensitive
Football
MRI = more sensitive
Gymnasts

Weight lifters
TREATMENT
MC = L5-S1
Treatment = mild & asymptomatic vs. symptomatic

Mild & asymptomatic = observation

SYMPTOMS & EXAM No restriction

Back pain = low back pain Symptomatic = activity restriction & PT

Sciatica Bracing = acute or failed PT

+/– hamstring tightness Complications = spondylolisthesis

Slippage of vertebrae at pars interarticularis

Forward slippage due to B/L spondylolysis

*BUZZ WORD*: SCOTTIE DOG DEFORMITY

VERTEBRAL COMPRESSION FRACTURE
KEY INFORMATION
Kyphoplasty = cement + balloon
Vertebroplasty = cement

ETIOLOGY / PATHO DIAGNOSIS

Fracture within vertebral body X-ray = loss of vertebral height

AKA wedge fracture

Pathologic fracture = in elderly, can occur with heavy TREATMENT

lifting or even spontaneously!
Treatment = supportive or surgery
Etiologies
Supportive = observation, pain meds, & brace
Elderly = osteoporosis
Surgery = kyphoplasty or vertebroplasty
Malignancy
Kyphoplasty = cement + balloon
Multiple myeloma
Vertebroplasty = cement
Prostate cancer

Systemic illness

SYMPTOMS & EXAM

Back pain

Midline tenderness = focal

*DON'T FORGET*: AKA WEDGE FRACTURE

SPINAL EPIDURAL ABSCESS
KEY INFORMATION
TRIAD = fever, back pain & neuro deficits
Bacterial infection

ETIOLOGY / PATHO DIAGNOSIS

Pus-filled collection CBC = ↑ WBCs
Etiologies
Osteomyelitis
↑ ESR & CRP
Diskitis MRI (with gadolinium) = ring-enhancing lesion
Pathogens
Staph aureus = MC
E. coli TREATMENT
Streptococcus
Mycobacterium tuberculosis Treatment = I&D and ABX

Risk factors I&D = interventional radiology -> CT & drainage

>50 years old
ABX = vancomycin + ceftriaxone
IVDA
Immunosuppression
HIV, DM, chemo drugs, & steroids
Epidural catheter placement
Recent spinal procedure

SYMPTOMS & EXAM

Triad = fever + spinal pain + neuro deficits

Back pain = focal & severe

Radiculopathy

Myelopathy = neuro deficits

*THINK ABOUT*: BACK PAIN & FEVER

CAUDA EQUINA SYNDROME
KEY INFORMATION
NEUROSURGICAL EMERGENCY
EMERGENT decompression

ETIOLOGY / PATHO DIAGNOSIS

Terminal spinal cord compression MRI = imaging of choice

Etiologies CT myelography = unable to perform MRI

Lumbar disc herniation = MC

Spinal stenosis TREATMENT

Trauma Treatment = surgery & meds

Tumors Surgery = EMERGENT decompression

Epidural abscess Steroids = ↓ inflammation

Epidural hematoma

Vertebral fractures

MC = L4-L5 or L5-S1

SYMPTOMS & EXAM

Back pain

Bilateral radicular symptoms

Leg pain/weakness

Saddle anesthesia = perineal sensory deficits

Urinary or bowel retention = MC

Urinary or bowel incontinence

↓ rectal tone
↓ DTRs

*DON'T FORGET*: SPINAL CORD COMPRESSION

THORACIC OUTLET SYNDROME
KEY INFORMATION
MC = women 20-50 years old
COMPRESSION of nerve/vascular

ETIOLOGY / PATHO DIAGNOSIS

Compression of brachial plexus, subclavian vein or MRI = confirms diagnosis

subclavian artery Special tests

Etiologies = congenital or trauma Adson sign = loss of radial pulse with head

rotation to ipsilateral or contralateral side

SYMPTOMS & EXAM

Nerve compression
TREATMENT
Treatment = supportive vs. surgery
Ulnar neuropathy
Supportive = PT & avoid strenuous activity
Atrophy = intrinsic hand muscles
Surgery = orthopedic consult
Vascular compression

Weak pulse

Swelling

Discoloration

*DON'T FORGET*: ADSON SIGN

ANTERIOR CRUCIATE LIGAMENT INJURIES
KEY INFORMATION
INTRA-ARTICULAR
Most common knee ligamental injury

ETIOLOGY / PATHO DIAGNOSIS

ACL = posterior femur to anterior tibia Special tests

Lachman = pulling tibia forward w/ 1 hand

INTRA-articular
Sensitive & specific = gold standard
Mechanism = NON-contact injury to ACL
Anterior drawer = both thumbs on knee & push
Deceleration backwards

Changing direction Pivot shift = while in internal rotation, valgus

Hyperextension force while knee is slowly flexed

X-ray = rule out fracture

Internal rotation
Segond fracture = avulsion of lateral tibial

SYMPTOMS & EXAM

condyle with varus stress to knee

Pathognomonic for ACL tear

“pop” & swelling MRI = best test to asses for ACL tears

ACL appears less taut

Hemarthrosis = immediate effusion

ACL is very vasculature & it’s intra-articular

Knee buckling = “giving way” -> instability

TREATMENT
Treatment = supportive vs. surgery

Supportive = sedentary lifestyle

NSAIDs

RICE

Physical therapy

Surgery = active lifestyle (prevents early DJD)

Allograft or autograft

Significant knee instability, young & active

patients, or high demand jobs or sports

*DON'T FORGET*: HEMARTHROSIS

POSTERIOR CRUCIATE LIGAMENT INJURIES
KEY INFORMATION
INTRA-ARTICULAR
Often occurs with LCL tear

ETIOLOGY / PATHO DIAGNOSIS

PCL = anterior femur to posterior tibia Special tests

INTRA-articular Posterior drawer = both thumbs on knee & pull

Mechanism forward

MVC = dashboard injury Sensitive & specific = gold standard

Hyperextension = ACL tearing through PCL Quadriceps active = posterior sag of tibia while at

Isolated PCL injury is RARE!! 90o, and repositioning (anterior movement) of

Often occurs with LCL tear tibia with activated quads

Sag sign = posterior sag of tibia

SYMPTOMS & EXAM X-ray = rule out fracture

MRI = best test to asses for PCL tears

Posterior knee pain

Anterior bruising
TREATMENT
NO frank instability
Treatment = supportive vs. surgery

Supportive = sedentary lifestyle

NSAIDs

RICE

Knee immobilization

Physical therapy

Surgery = instability or occurring wit multiple injuries

*DON'T FORGET*: OCCURS WITH LCL

MEDIAL COLLATERAL LIGAMENT INJURIES
KEY INFORMATION
EXTRA-ARTICULAR
Valgus force

ETIOLOGY / PATHO DIAGNOSIS

MCL = medial femur to medial tibia Special tests

EXTRA-articular Valgus stress test = medial knee pressure

Mechanism = valgus force 0o (combined) = complete extension

Testing both MCL & some capsule

SYMPTOMS & EXAM 30o (isolated MCL) = a little flexion

Testing only MCL (more sensitive)

Medial knee pain
MRI = not indicated UNLESS possible ACL tear
Able to bear weight -> painful ambulation

NO effusion (b/c it is extra-articular)

TREATMENT
Treatment = supportive vs. surgery

Supportive = most common

Hinged knee brace = isolated MCL tear

6-8 weeks

Prevents secondary valgus bow

NOT knee immobilizer

Then knee will get stiff & scarred

Therapeutic exercise

Surgery = severe

*DON'T FORGET*: VALGUS FORCE

LATERAL COLLATERAL LIGAMENT INJURIES
KEY INFORMATION
EXTRA-ARTICULAR
Varus force

ETIOLOGY / PATHO DIAGNOSIS

LCL = lateral femur to lateral tibia Special tests

EXTRA-articular Varus stress test = lateral knee pressure

Mechanism = varus force MRI = not indicated UNLESS possible PCL tear

SYMPTOMS & EXAM TREATMENT

Lateral knee pain Treatment = supportive vs. surgery

Supportive = most common

Hinged knee brace = isolated MCL tear

6-8 weeks

Prevents secondary valgus bow

NOT knee immobilizer

Then knee will get stiff & scarred

Therapeutic exercise

Surgery = severe

*DON'T FORGET*: VARUS FORCE

 MENISCUS TEAR
KEY INFORMATION
Lateral meniscus = “O” shaped
Medial meniscus = “C" shaped

ETIOLOGY / PATHO DIAGNOSIS

Lateral meniscus = “O” shaped Special tests

McMurray = patient is supine; pain with internal

Medial meniscus = “C" shaped
rotation (lateral meniscus) or pain
Types
Apley compression = patient is prone; pain with
Acute tear = young kids playing sports
internal rotation (lateral meniscus) or pain with
Twisting or pivoting of foot
external rotation (medial meniscus) with external
Single & discrete tear
rotation (medial meniscus)
Degenerative tear = elderly patients
Bounce home = knee does not fall into full extension
Degenerative = 2o to DJD
when legs extended & bounced
Frayed & ratty = no specific tear
Thessaly = stand on one leg (affected leg) and try to

reproduce symptoms

SYMPTOMS & EXAM MRI = +/– for acute injuries

NOT for DJD knees -> all have meniscus tears

Mechanical symptoms = clicking, locking, etc.

Effusion = synovial fluid -> usually next day

Meniscus doesn’t have good blood supply TREATMENT

Joint line tenderness Treatment = supportive vs. surgery

Supportive = most common

NSAIDs

RICE

Physical therapy

Orthopedic follow-up

Surgery = severe symptoms, poor function, persistent

symptoms (“knee locking”), significant tear, etc.

*DON'T FORGET*: JOINT LINE TENDERNESS

PATELLAR FRACTURE
KEY INFORMATION
DIRECT blow
Rule out bipatellar tendon

ETIOLOGY / PATHO DIAGNOSIS

Types X-ray = lateral view & sunrise view

Nondisplaced Rule out bipatellar tendon -> smooth margins

Transverse = MC

Lower or upper pole TREATMENT

Comminuted displaced vs. nondisplaced Treatment = supportive vs. surgery

Mechanism = direct blow Supportive = non-displaced or avulsion

Knee immobilizer

SYMPTOMS & EXAM WBAT

Early active ROM after healing

Pain & swelling
Surgery = displaced (>3 mm), comminuted,
Limited knee extension
loss of extensor function, or articular step-off
Tenderness over patella
Tension wire
Hemarthrosis
Circlage
+/– palpable patellar defect
Screw fixation

*DON'T FORGET*: RULE OUT BIPATELLAR TENDON

OSGOOD-SCHLATTER DISEASE
KEY INFORMATION
MC = athletes & growth spurts
Overuse injury

ETIOLOGY / PATHO DIAGNOSIS

Apophysitis of tibial tuberosity X-ray = elevation, heterotopic ossification, &

Inflammation of patellar tendon at tibial bone fragmentation

tubercle insertion

Mechanism = overuse injury TREATMENT

Small avulsions from repetitive knee Treatment = supportive vs. surgery

extension & quadriceps contraction Supportive = non-displaced or avulsion

RICE

SYMPTOMS & EXAM NSAIDs

Quadriceps stretching
Pain & swelling
Knee immobilization
TTP to anterior tibial tubercle
Surgery = refractory cases

After closed growth plate

*DON'T FORGET*: GROWTH SPURTS

PATELLAR & QUADRICEPS TENDON RUPTURES
KEY INFORMATION
Quadricep rupture = MC >40 years old
Patellar rupture = MC <40 years old

ETIOLOGY / PATHO DIAGNOSIS

Mechanism = forceful quadriceps contraction X-ray = high vs. low riding patella

Fall on flexed knee MRI = better look at tendons

Walking up/downstairs

Risk factors TREATMENT

Gout
Treatment = supportive vs. surgery
DM
Supportive = non-displaced or avulsion
Obesity
RICE
Renal disease
NSAIDs
EtOH
Knee immobilization = full extension
Steroid abuse = anabolic steroids
Surgery = ASAP -> within 2 weeks!

SYMPTOMS & EXAM

Sharp & proximal knee pain

Focal tenderness to palpation

Focal defect to palpation

Quadricep rupture = defect ABOVE knee

Low-riding patella (patella baja)

Patellar rupture = defect BELOW knee

High-riding patella (patella alta)

UNABLE to extend knee

UNABLE to do active straight leg raise

*THINK ABOUT*: "QUAD ABOVE & PATELLAR BELOW"

TIBIAL PLATEAU FRACTURE
KEY INFORMATION
MC = lateral
Occurs with ligament and meniscus injury

ETIOLOGY / PATHO DIAGNOSIS

Mechanism = axial load, rotation, & trauma Schatzker classification = six different types

Axial load = fall from height Lipohemarthrosis = bone marrow & blood

Trauma = MVA Seen on x-ray or CT

Often with ligament & meniscus injury X-ray = prior to checking ligaments!

AP, lateral, & 2 obliques

SYMPTOMS & EXAM CT = if (+) x-ray -> for surgical planning

Pain & swelling MRI = suspect soft tissue injury

Hemarthrosis

TREATMENT
Treatment = supportive vs. surgery
Supportive = non-displaced or minimally
displaced
Long leg splint or knee immobilizer
NWB = crutches
RICE
Analgesia
Ortho follow-up = within 1-week
Warn patient of S/S of compartment
syndrome!
Surgery = significant displacement
External fixation = percutaneous pins
Allow for skin to heal before they fix it
ORIF
Complications = compartment syndrome

*DON'T FORGET*: 6 DIFFERENT TYPES

PATELLOFEMORAL SYNDROME
KEY INFORMATION
(+) theater sign & "C" sign
(+) apprehension sign

ETIOLOGY / PATHO DIAGNOSIS

Retropatellar articular cartilage softening Clinical diagnosis

Usually bilateral (+) apprehension sign

Mechanism = overuse injury

Risk factors TREATMENT

Overactivity = runner or cyclist Treatment = supportive vs. surgery

Muscle imbalance Supportive

Brace or sleeves
Patella mal-alignment
Physical therapy
Stretch hamstrings

SYMPTOMS & EXAM Strengthen quadriceps & hip abductors

Pain meds
Knee pain
Weight loss
Worse = sitting, stairs, running Surgery = severe cases

Loaded flexion

(+) theater sign = knee pain after sitting at 90o

(+) “C”sign = grasp knee with hand in shape of a

C instead of directly pointing

Pseudo-locking

Retro-patellar tenderness

Patella grind test

*THINK ABOUT*: KNEE PAIN & RUNNER

 ILIOTIBIAL BAND SYNDROME
KEY INFORMATION
(+) cross over test
AGGRESSIVE ITB band stretching

ETIOLOGY / PATHO DIAGNOSIS

Inflammation of iliotibial band bursa Special tests

Risk factors Noble compression test = pain over distal IT

Runners band at 30o flexion

Cyclist Ober test = pain or resistance to adduction of

leg while patient lying on their side

SYMPTOMS & EXAM

Sharp & burning knee / hip pain = lateral TREATMENT
Worse = change in terrain (stairs or downhill) Treatment = supportive
Supportive
Improve = rest
NSAIDs
(+) cross over test
RICE
Massage & therapeutic US if needed
Aggressive ITB stretching
With crossfit foam roller

*THINK ABOUT*: LATERAL KNEE/HIP PAIN

 A N K L E S P R A I N
KEY INFORMATION
*Amount of swelling/ecchymosis DOES NOT correlate

with degree of sprain or sign of fracture*

ETIOLOGY / PATHO DIAGNOSIS

Ottawa Ankle Rules = tenderness to certain areas
Types
Lateral malleolus
Lateral (MC) = inversion Tip of media malleolus
Base of 5th metatarsal
Anterior talofibular ligament = MC
Navicular
Posterior talofibular ligament (Don’t use Ottawa on kids, intoxicated or distracting injury!)

Calcaneofibular ligament X-ray = AP, oblique, lateral

(+) Ottawa
Medial = eversion Cannot walk >4 steps immediately & in ED
Deltoid ligament MRI = +/– if pain >6 weeks
Special tests
Syndesmosis (high-ankle) = externally Lateral
rotated foot Inversion stress test = invert foot
Anterior drawer = pull ankle forward
Anterior tibiofibular ligament Injured anterior talofibular ligament
Posterior tibiofibular ligament Medial
Eversion stress test = evert foot
Risk factors
Syndesmosis
Females > males Kleiger’s test = externally rotate foot
Grading system
Children/teenagers > adults
Grade I = stretched ligament
Indoor court sports > outdoor Grade II = partially torn ligament
Grade III = fully torn (ruptured) ligament
Natural grass > artificial turf
Defensive player > offensive player
TREATMENT
Treatment = supportive
SYMPTOMS & EXAM Supportive
Immobilization = grade II & III
NSAIDs
Pain & swelling
RICE
Inability to bear weight Rest = limited WB (crutches)
1-3 days
Ecchymosis Ice = 2-3 days until inflammatory phase over
↓
Compression = ACE hydrostatic pressure
Syndesmosis = proximal ankle pain Elevation = above heart
Therapeutic exercises
Stretching/ROM & strengthening
Helps prevent chronic instability
Return to full WB as tolerated

*DON'T FORGET*: SYNDESMOSIS = HIGH-ANKLE

 J O N E S F R A C T U R E
KEY INFORMATION
Zone 2 = Jones fracture
5th metatarsal

ETIOLOGY / PATHO DIAGNOSIS

Types X-ray = transverse fracture

Zone 1 = avulsion fracture (MC) Involving metaphyseal-diaphyseal junction

Fibular brevis attaches at 5th metatarsal
When you invert ankle, fibularis brevis
tries to bring back into eversion TREATMENT
Zone 2 = Jones fracture Treatment = supportive vs. surgery
Transverse fx through 5th metatarsal Zone 1 = non-operative & can treat in PCP
Problematic due to poor bloody supply
Zone 2 = non-operative or operative
Watershed area
Refer to ortho b/c of high incidence of non-union
Zone 3 = stress fracture
Mechanism = traumatic or overuse fractures
Early WB ↑ risk of malunion
Zone 3 = non-operative at first & can treat in PCP
Inversion ankle injuries
Direct blow If not healing, refer to ortho for possible surgery

Twisting of the foot Complications = non-union (Jones fracture)

SYMPTOMS & EXAM

Pain = 5th metatarsal & lateral midfoot

*DON'T FORGET*: 5TH METATARSAL

LISFRANC FRACTURE
KEY INFORMATION
Dorsal ligament = Lisfranc ligament
Fleck sign

ETIOLOGY / PATHO DIAGNOSIS

Tarsometatarsal (Lisfranc) joint complex X-ray = AP, oblique, lateral -> weight bearing!

Disruption between medical cuneiform & base Often misread as normal!

of 2nd metatarsal
Fleck sign = fracture at base of 2nd
Dorsal ligament = Lisfranc ligament
metatarsal pathognomonic for disruption of
Most often happens to this joint
But can happen anywhere along joint line tarsometatarsal ligaments

Mechanism = rotational & severe axial load CT or MRI = better imaging choice!
MVA
Falls
Axial load TREATMENT
Plantar flexion & someone falls on foot Treatment = acute vs. long-term

Types = rotational & sever axial load Acute

Lisfranc fracture
Immobilize = splint or CAM walker
Lisfranc dislocation
NWB = crutches
Lisfranc “injury” = tear Lisfranc ligament
Referral to orthopedics

Long-term = non-operative or operative

SYMPTOMS & EXAM Non-operative = immobilize 6-10 weeks, then PT

Pain & swelling Operative = ORIF

Inability to bear weight

Ecchymosis

Tenderness over tarsometatarsal joint

↓ ROM
↓ strength

*DON'T FORGET*: TARSOMETATARSAL JOINT

ACHILLES TENDON RUPTURE
KEY INFORMATION
↑ sports = ↑ rate of tendon ruptures
(+) Thompson test

ETIOLOGY / PATHO DIAGNOSIS

Rupture of achilles tendon Clinical diagnosis

Mechanism (+) Thompson test = weak or absent plantar

Running flexion with gastrocnemius squeeze

Jumping US = done at bedside

Sudden acceleration or deceleration MRI = uncertain clinically and US (–)

Risk factors

Fluroquinolone = 1st 90 days

Steroids = PO or injections
TREATMENT
Treatment = acute vs. long-term
30-50 years old
Acute
Male

Achilles tendon = “water shed” area Immobilize (splint or CAM walker)

Poor blood supply = 2-6 cm above insertion Heel lift = takes stress off Achilles

Most ruptures occur here NWB = crutches

Happens above calcaneus Referral to orthopedics = 1-2 days

Long-term = non-operative or operative

SYMPTOMS & EXAM Non-operative = immobilize 6-8 weeks

with heel lift

SUDDEN heal pain
Operative = repair vs. reconstruction
“pop”

Inability to weight bear

Some patients can plantarflex

Other muscles help with plantar flexion!

Maybe fibularis longus or tibialis posterior

*DON'T FORGET*: SUDDEN HEAL PAIN

 PLANTAR FASCIITIS
KEY INFORMATION
Flat feet = risk factor
Plantar stretching exercises

ETIOLOGY / PATHO DIAGNOSIS

Inflammation & micro tears of plantar fascia Clinical diagnosis

Mechanism = overuse injury X-ray = might show heel spur (NOT helpful)

Risk factors Heel spur from walking different

Flat feet Heels spurs do NOT cause pain!

High arches

Heel spurs TREATMENT

Female Treatment = supportive, steroids, & surgery
40-60 years old Supportive
Obese RICE
Faulty running shoes NSAIDs

Heel & arch support

SYMPTOMS & EXAM PT = plantar stretching exercises

Inferior heel pain Steroids (injections) = refractory to NSAIDs

Worse = AM (1st few steps) & PM (end of day) Surgery = refractory to NSAIDs & steroids

Improve = activity, walking, massage,

stretching, & rest

Local point tenderness

Pain with dorsiflexion of toes = stretching fascia

*THINK ABOUT*: PAIN WITH FIRST STEP

TARSAL TUNNEL SYNDROME
KEY INFORMATION
Tibial nerve compression
(+) tinel sign

ETIOLOGY / PATHO DIAGNOSIS

Clinical diagnosis
Posterior tibial nerve compression
(+) tinel sign = tapping tarsal tunnel (posterior
Risk factors
medial malleolus) reproduces symptoms
Overuse

Restrictive footwear

Edema
TREATMENT
Treatment = conservative, steroids, & surgery

SYMPTOMS & EXAM Conservative

RICE
Pain & numbness = medial malleolus, heel & sole
NSAIDs
Worse = during day, at night, & dorsiflexion
Heel & arch support
NO improvement with rest
PT = plantar stretching exercises

Steroids (injections) = refractory to NSAIDs

Surgery = refractory to NSAIDs & steroids

*THINK ABOUT*: PAIN & NUMBNESS

NEUROPATHIC ARTHROPATHY
KEY INFORMATION
AKA Charcot-Marie-Tooth disease
DIABETES = risk factor

ETIOLOGY / PATHO DIAGNOSIS

X-ray = obliteration of joint space, fragmentation
Joint damage & destruction from neuropathy

↓ sensation, autonomic dysfunction & of bone, ↑ bone density, & disorganized joint
repetitive microtrauma

Bone resorption & weakening

TREATMENT
Risk factors Treatment = conservative vs. surgery

Conservative = accommodative footwear

DM
Surgery = severe deformity
PVD

Tabes dorsalis = form of tertiary syphilis

SYMPTOMS & EXAM

Acute = swollen & warm

Chronic = joint or foot deformity, altered shape of

foot, ulcer or skin changes

*THINK ABOUT*: DIABETES & FOOT PAIN

INTERDIGITAL NEUROMA
KEY INFORMATION
Interdigital NERVE compression/entrapment
(+) metatarsal compression test

ETIOLOGY / PATHO DIAGNOSIS

Clinical diagnosis
Entrapment/compression of interdigital nerve
X-ray = not helpful
Perineural fibrosis of common digital nerve
US or MRI = show most, but not all
MC = 2nd & 3rd web spaces
(+) metatarsal compression test = try to
AKA Morton's Neuroma
reproduce symptoms
Risk factors
(+) mulder’s sign = clicking sensation when
Running
palpating interspace white squeezing MT joint
Ballet

High heels

Narrow toe box shoes

TREATMENT
Treatment = conservative, steroids, or surgery
Flat feet
Conservative

SYMPTOMS & EXAM Metatarsal support or pad

Broad-toed shoes with firm soles

Burning & stinging pain
Steroids (injections) = refractory to NSAIDs
Worse = WB (weight bearing)
Surgery = refractory to NSAIDs & steroids
"pebble” or “rock” in shoe

Numbness/tingling into toes

*THINK ABOUT*: PAIN & HARD KNOT ON FOOT

 B A K E R ’ S C Y S T
KEY INFORMATION
Cyst formation
Mimics DVT!

ETIOLOGY / PATHO DIAGNOSIS

US = best initial test (rule out DVT)
Synovial fluid displaced with cyst formation
X-ray = joint abnormalities associated with cyst
Risk factors

Degenerative joint disease

Inflammatory joint disease

TREATMENT
Treatment = conservative, steroids, or surgery

SYMPTOMS & EXAM Conservative

RICE
Posterior knee pain
Assisted weight bearing
Stiffness
NSAIDs
Mass behind knee
Steroids (injections) = refractory to conservative
Knee effusion
Surgery = refractory to conservative & steroids
Ruptured cyst = tenderness, warmth, & erythema

Mimics DVT!

*THINK ABOUT*: POSTERIOR KNEE PAIN & MASS

H I P D I S L O C A T I O N
KEY INFORMATION
Posterior = internally rotated
Anterior = externally rotated

ETIOLOGY / PATHO DIAGNOSIS

X-ray = initial imaging of choice
Mechanism = trauma (MC)
Posterior = femoral head small & adducted
MVC
Anterior = femoral head large & abducted
Fall from height

Types

Posterior = MC
TREATMENT
Treatment = conservative vs. surgery
Axial loading on adducted femur
Conservative
Anterior
Closed reduction with conscious sedation
Axial loading on abducted femur
Surgery = severe or associated fracture

ORIF

SYMPTOMS & EXAM Complications = avascular necrosis of femoral head,

Groin pain DVT, femoral artery injury, sciatic nerve injury, &

Posterior = internally rotated & adducted femoral nerve injury (anterior)

Shortened Sciatic nerve injury = loss of sensation to posterior

Anterior = externally rotated & abducted leg & foot, loss of dorsiflexion & plantar flexion, &

loss of DTR at foot

Femoral nerve injury = loss of sensation over

thigh, weak quadriceps, & loss of DTR at knee

Femoral artery injury = hematoma, no pulse, pale

*THINK ABOUT*: TRAUMA AND GROIN PAIN

 H I P F R A C T U R E
KEY INFORMATION
Externally rotated leg
Shortened leg

ETIOLOGY / PATHO DIAGNOSIS

X-ray = initial imaging of choice
Mechanism = depends on age

Minor or indirect trauma = elderly

High-impact = younger patients

TREATMENT
Treatment = conservative vs. surgery
Types = depends on age
Conservative = high surgical risk, minimal pain,
Femoral neck = intracapsular
non-ambulatory prior to fracture
Higher incident of avascular necrosis
Surgery = ORIF or arthroplasty
Intertrochanteric = extracapsular

Subtrochanteric = extracapsular

SYMPTOMS & EXAM

Leg = shortened, externally rotated, abducted

Hip, thigh, or groin pain

*THINK ABOUT*: HIGH-TRAUMA (YOUNG) LOW-TRAUMA (OLD)

LEGG-CALVE-PERTHES DISEASE
KEY INFORMATION
Avascular necrosis of femoral head
(+) crescent sign

ETIOLOGY / PATHO DIAGNOSIS

X-ray = widened cartilage space; (+) crescent
Avascular necrosis of femoral head = idiopathic
sign (microfracture w/ collapsed bone)
Lack of blood flow = osteonecrosis

Risk factors

4-10 years old TREATMENT

Male Treatment = conservative vs. surgery

Conservative = self-limiting with

Obesity
revascularization within 2 years
Coagulopathy = Factor V Leiden
Activity restriction = NBW
Caucasian
Orthopedic follow-up

SYMPTOMS & EXAM PT or brace/cast

NSAIDs
PAINLESS limp
Surgery = advanced disease
Hip, thigh, groin or knee pain

↓ ROM = loss of abduction & internal rotation

*BUZZ WORD*: OBESE WHITE BOY & PAINLESS LIMP

SLIPPED CAPITAL FEMORAL EPIPHYSIS
KEY INFORMATION
Occurs during rapid growth
“ice cream falling from cone”

ETIOLOGY / PATHO DIAGNOSIS

X-ray = posterior displacement of femoral
Displaced femoral head from femoral neck
epiphysis; “ice cream falling from cone”
Risk factors
Early sign = widening & irregularity of physis
8-16 years old
Blurring metaphyseal-growth plate junction
Male
Frog-leg view
Obesity
CT or MRI = additional imaging if needed
Growth spurt = weak growth plate &
Drehmann sign = while supine, hip externally
hormonal change at puberty
rotates and abducts with passive hip flexion
African American

Before puberty = hormonal or systemic disorder

TREATMENT
(hypothyroidism or hypopituitarism)
Treatment =acute vs. long-term

Acute = NWB & rest

SYMPTOMS & EXAM Long-term = surgery -> internal fixation & pinning

PAINFULL limp Complications = avascual necrosis of femoral head

Hip, thigh, groin or knee pain

↓ ROM = loss of abduction & internal rotation

Shortened & externally rotated

Inability to bear weight

Evaluate both hips -> 25-50% bilateral

*BUZZ WORD*: OBESE OLDER BOY & PAINFUL LIMP

TROCHANTERIC BURSITIS
KEY INFORMATION
Irritated or inflamed bursa
"Put out a cigarette" = LATERAL HIP PAIN

ETIOLOGY / PATHO DIAGNOSIS

Clinical diagnosis
Irritated or inflamed bursa

Etiologies

Trauma = MC TREATMENT
Repetitive irritation = MC Treatment = conservative vs. steroids

Conservative
Ex: = runner
Analgesics & NSAIDs
Infectious = rare!
RICE

Therapeutic US
SYMPTOMS & EXAM IT band stretching = crossfit roller
Hip pain = specific & well-localized lateral pain
Fascia = NOT muscle or tendon

Evaluation = put hand at hip & have them due IR Hard to stretch

& ER femur (“put out a cigarette”) Steroids (injections) = refractory to conservative

Inject at point of maximal tenderness

*THINK ABOUT*: RUNNER & LATERAL HIP PAIN

SNAPPING HIP SYNDROME
KEY INFORMATION
Young female athlete
Audible click

ETIOLOGY / PATHO DIAGNOSIS

Clinical diagnosis
Anterior or lateral hip pain + audible click

Risk factors

Young females TREATMENT

Athletes Treatment = conservative

Types Conservative

Analgesics & NSAIDs

External snapping syndrome (lateral)
Therapeutic exercise
Tendon = IT band
Stretching
Grater trochanter

Internal snapping syndrome (anterior)

Tendon = iliopsoas tendon

Iliopectineal eminence

SYMPTOMS & EXAM

Audible click

Snapping with flexion, extension, or abduction

+/ – hip pain = often click WITHOUT pain

*THINK ABOUT*: YOUNG FEMALE ATHLETE

GLENOHUMERAL DJD
KEY INFORMATION
Hip arthritis
X-ray help educate patient on arthritis

ETIOLOGY / PATHO DIAGNOSIS

X-ray
Degeneration (wear & tear) of articular cartilage
Solidify diagnosis
Overgrowth of bone (osteophytes)
Aid in tracking progression
Narrowing of joint space
Patient education
Joint surface hardening (sclerosis)

Results in joint deformity

NOT usually associated with inflammation

TREATMENT
Treatment = conservative, injections, & surgery
Risk factors
Conservative
History of surgery or instability
NSAIDs
>50 years old
Therapeutic exercise
Trauma
Glucosamine supplement

Injections = steroids or hyaluronic acid

SYMPTOMS & EXAM Surgery = arthroplasty

Crepitus

Pain

Clicking

Mechanical symptoms

*THINK ABOUT*: HIP ARTHRITIS

ACROMIOCLAVICULAR SPRAIN / DISLOCATION

KEY INFORMATION
"Piano key” sign
Zanca view on X-ray

ETIOLOGY / PATHO DIAGNOSIS

Grading system = 1-6
AC sprain = shoulder separation
Grade I = overstretching (sprain)
Mechanism = fall directly onto lateral shoulder
Grade II = tears (with weakness)
Shoulder ligaments
Grade III = complete ligament disruption
Acromioclavicular = horizontal stability
Grade IV-VI = displacement
Coracoclavicular = vertical stability
X-ray = Zanca view (with & without weights)

Special tests
SYMPTOMS & EXAM Horizontal flexion (cross body) = pain
Pain with active ROM -> overhead activities
“Piano key” sign = step-off deformity when
↓ strength (2° pain) you push down on clavicle (see if it moves)
Step-off deformity

Tenderness @ AC joint
TREATMENT
Treatment = depends on grade
Grade I & II = conservative (non-operative)
Sling 1-2 weeks prn -> use it as they please
ROM & strengthening after sling
Patient education = make sure to address this!
Very painful!
May have lasting deformity
Not completely better for 6-8 weeks
Grade III = conservative & surgery
Persistent symptoms
Surgery has high failure rate
Grade IV-VI = surgery

*THINK ABOUT*: SHOULDER PAIN AFTER FALL

ANTERIOR GLENOHUMERAL DISLOCATION

KEY INFORMATION
Abducted & ER arm
Bankart lesion

ETIOLOGY / PATHO DIAGNOSIS

X-ray = axillary & scapular “Y” views
Mechanism
Hillsach lesion = groove fx of humerus
Blow to abducted & ER arm
Bankart lesion = glenoid rim fracture
FOOSH
CT or MRI = additional imaging if needed
Posterior humeral force

SYMPTOMS & EXAM TREATMENT

Treatment = reduction & immobilization
Abducted & ER arm (elbow pointing outward)
Complications = axillary nerve injury, axillary
Humeral head palpable inferiorly artery injury, brachial plexus injury, suprascapular
nerve injury, & radial nerve injury

*THINK ABOUT*: ABDUCTED & ER ARM

POSTERIOR GLENOHUMERAL DISLOCATION

KEY INFORMATION
Adducted & IR arm
Light bulb sign

ETIOLOGY / PATHO DIAGNOSIS

X-ray = axillary & scapular “Y” views
Mechanism = forced adduction & IR
Light bulb sign = humeral head appears to
Seizure
look like a light bulb
Electric shock
CT or MRI = additional imaging if needed
Trauma

SYMPTOMS & EXAM TREATMENT

Treatment = reduction & immobilization
Adducted & IR arm
Complications = axillary nerve injury, axillary
artery injury, brachial plexus injury, suprascapular
nerve injury, & radial nerve injury

*THINK ABOUT*: ADDUCTED & IR ARM

B I C I P I T A L T E N D O N I T I S

KEY INFORMATION
Often with impingement or RTC tear
(+) yergasons test

ETIOLOGY / PATHO DIAGNOSIS

Special tests
Overuse/repetitive syndrome
(+) yergasons test = elbow flexion & push
NOT an injury
against resistance & palpate bicipital groove
Risk factors
(+) speeds test = supination & push against
Baseball, tennis, volleyball, or swimming
resistance & palpate bicipital groove
Painters

TREATMENT
Carpenters

Technicians
Treatment = conservative vs. steroids

Conservative
SYMPTOMS & EXAM RICE

Shoulder pain = anterior Tylenol vs. NSAIDS

Worse = overhead motion or throwing PT / therapeutic exercises= strengthen muscles

Work restrictions
TTP in bicipital groove
Therapeutic US
Pain/weakness with arm & forearm flexion
Steroids = refractory to conservative

NO steroid injections into tendon

Could tear it!

Fluro guided & US guided into tendon sheath

*THINK ABOUT*: TENDERNESS IN BICIPITAL GROOVE

 S L A P T E A R S

KEY INFORMATION
(+) yergasons test
(+) O’Brien’s test

ETIOLOGY / PATHO DIAGNOSIS

Superior labrum anterior to posterior Special tests
Tear of top of labrum from front to back
(+) yergasons test = elbow flexion & push
SLAP tear = disruption of biceps tendon anchor
against resistance & palpate bicipital groove
Labrum = “bumper” anteriorly & posteriorly
Superior labrum = biceps anchor (+) speeds test = supination & push against
Mechanism
resistance & palpate bicipital groove
Traumatic = acute injury
(+) O’Brien’s test = pain with shoulder flexion
Degenerative = overuse
Types resistance with palm down, but not up
Type I = fraying labrum by bicep insertion
Type II = avulsion/detachment of superior
labrum & biceps anchor TREATMENT
Anchor disrupted Treatment = depends on types
Type III = bucket-handle tear of superior
Type 1 = debridement -> fast (~2 weeks)
labrum & biceps anchor intact
Type 2 = repair (sutures/anchors) -> slow (12 weeks)
Type IV = bucket-handle tear of superior
labrum that extends into biceps tendon Type 3 = debridement -> fast (~2 weeks)

Anchor disrupted Type 4 = repair (sutures/anchors) -> slow (12 weeks)

SYMPTOMS & EXAM

Shoulder pain = anterior

Worse = overhead motion or throwing

TTP in bicipital groove

Pain/weakness with arm & forearm flexion

*THINK ABOUT*: TENDERNESS IN BICIPITAL GROOVE

S H O U L D E R I N S T A B I L I T Y

KEY INFORMATION
(+) sulcus sign
(+) anterior apprehension test

ETIOLOGY / PATHO DIAGNOSIS

X-ray = pre & post reduction
Types
Special tests
Traumatic = glenohumeral dislocation or
(+) sulcus sign = pulling inferiorly on arm
subluxation
displaces it inferiorly
Bankart tear = anterior labrum
(+) anterior apprehension test = pain with
Reverse Bankart tear = posterior labrum
shoulder flexion while shoulder abducted & elbow
Atraumatic = hyperligamentous laxity
flexed
Swimmers
(+) jobe relocation test = pressing on anterior
Ehlers-Danlos
shoulder after apprehnesion test relieves pain
Marfan
(+) posterior drawer = shoulder & elbow flexed &

SYMPTOMS & EXAM

pain with axial load posteriorly

Traumatic = deformity & instability

TREATMENT
Atraumatic = deformity & multi-instability
Treatment = reduction

*THINK ABOUT*: TRAUMATIC VS. ATRAUMATIC

A D H E S I V E C A P S U L I T I S

KEY INFORMATION
AKA frozen shoulder
Gradual return of ROM = 18-24 months

ETIOLOGY / PATHO DIAGNOSIS

Shoulder stiffness 2o to inflammation Clinical diagnosis

Involves glenohumeral joint & capsule

Etiology = immobilization for a long time TREATMENT

Risk factors Treatment = PT, steroids + ROM vs. lysis of adhesions

Hypothyroidism Conservative = PT with ROM exercises (1st line)

DM Steroids & ROM = fluoro guided steroid injection

Prolonged immobilization with aggressive ROM

CVA Glenohumeral intra-articular steroid injection

Autoimmune Aggressive ROM to break up adhesions!

Steroid injection before b/c it will be painful

SYMPTOMS & EXAM Lysis of adhesions = manipulation under

anesthesia
Shoulder pain & stiffness
Fail injections x2 -> they go to OR
Worse = at night
Shave adhesions then surgeon moves arm
↓ active & passive ROM = worse with ER

*DON'T FORGET*: HYPOTHYROIDISM & DIABETES

ROTATOR CUFF IMPINGEMENT

KEY INFORMATION
MC = >40 years old
Night pain

ETIOLOGY / PATHO DIAGNOSIS

Special tests
Impingement of supraspinatus tendon
(+) neer test = pain with flexion of shoulder with palm
RTC stabilizes humeral head
facing down
Rotator cuff muscles are dynamic stabilizers Impingement
During abduction, rotator cuff depresses (+) hawkins-kennedy test = elbow & shoulder flex with

humeral head pain with IR

Impingement
No stabilization = nerve impingement
(+) empty can test = thumb down & pain with shoulder
2o impingement = pinching RTC (supraspinatus)
flexion resistance
due to excessive humeral head movement Tear (strength test)
1o impingement = pinching RTC (supraspinatus) (+) ER test = pain with ER

due to anatomic abnormality Tear (strength test)

(+) drop arm test = pain with lowering arm from 90o
Acromion shape & inflamed SA bursa
abduction
Mechanism = chronic overuse & trauma Tear (strength test)
Risk factors = athletes, labor, elderly, smoking (+) strength / ↓ strength then a tear! -> get MRI
Rotator cuff MRI = arthrogram
MRI dye (gadolinium) into shoulder
Supraspinatus = MC
Gadolinium = contrast & inflate joint for better
Infraspinatus
visualization
Teres minor
Subscapularis
TREATMENT
SYMPTOMS & EXAM Treatment = conservative, steroids, vs. surgery
Conservative
Shoulder pain = anterolateral NSAIDS
PT / therapeutic exercises
Worse = combing hair or reaching for wallet
Strengthen muscles
↓ ROM with overhead activities, ER & abduction Rest = NO sling (minimal rest)
passive ROM > active ROM Steroids = subacromial steroid injection
Inability to sleep on affected side Surgery = failed conservative & steroids
Full tear or >50% partial tear = surgery
Shoulder pain = anterolateral
<50% partial tear = conservative
Night pain = wakes from sleep (rotator cuff tear)

*THINK ABOUT*: SHOULDER PAIN AT NIGHT

 ROTATOR CUFF TEAR

KEY INFORMATION
FOOSH = fall on outstretched hand
Night pain

ETIOLOGY / PATHO DIAGNOSIS

Special tests
Mechanism = FOOSH
(+) neer test = pain with flexion of shoulder with palm

Types facing down

Impingement
Partial-thickness tear (+) hawkins-kennedy test = elbow & shoulder flex with
pain with IR
Bursal side = top tear by acromion
Impingement
Articular side = bottom tear by humerus (+) empty can test = thumb down & pain with shoulder
flexion resistance
Complete (full-thickness) tear Tear (strength test)
(+) ER test = pain with ER
Massive = multiple tendons or retracting
Tear (strength test)
Full thickness tear of multiple tendons (+) drop arm test = pain with lowering arm from 90o
abduction
Tendon pulls toward body & retracts
Tear (strength test)

Causes a lot more pain (+) strength / ↓ strength then a tear! -> get MRI
MRI = arthrogram
Muscle is not being used -> atrophy MRI dye (gadolinium) into shoulder
Gadolinium = contrast & inflate joint for better
MRI = fat in muscle
visualization

SYMPTOMS & EXAM TREATMENT

Treatment = conservative, steroids, vs. surgery
Shoulder pain = anterolateral
Conservative
Worse = combing hair or reaching for wallet NSAIDS

↓ ROM with overhead activities, ER & abduction PT / therapeutic exercises

Strengthen muscles
passive ROM > active ROM Rest = NO sling (minimal rest)
Steroids = subacromial steroid injection
Inability to sleep on affected side
Surgery = failed conservative & steroids
Shoulder pain = anterolateral Full tear or >50% partial tear = surgery
<50% partial tear = conservative
Night pain = wakes from sleep (rotator cuff tear)

*THINK ABOUT*: SHOULDER PAIN AT NIGHT

 CLAVICLE FRACTURE

KEY INFORMATION
Most commonly fractured bone in shoulder
TENTING of skin

ETIOLOGY / PATHO DIAGNOSIS

X-ray = best initial imaging
Mechanism

Fall

Direct blow (anterior)

TREATMENT
Treatment = acute vs. long-term
Classification
Acute = sling
Group 1 = midshaft (middle) 1/3 -> MC
Long-term = conservative & surgery
Group 2 = distal (lateral) 1/3
Conservative = sling
Group 3 = proximal (medial) 1/3
Surgery = ORIF

Open
SYMPTOMS & EXAM Severe skin tenting

Pain with ROM Severe shortening

Deformity 100% displacement

Tenting of skin Severe comminution

NOT for cosmetics

Crepitus
Complications = PTX, hemothorax, coracoclavicular

ligament disruption, & brachial plexus injury

*DON'T FORGET*: SKIN TENTING

LATERAL EPICONDYLITIS

KEY INFORMATION
AKA Tennis Elbow
MC = >40 years old

ETIOLOGY / PATHO DIAGNOSIS

Clinical diagnosis
Inflammation of tendon insertion of extensor

carpi radialis brevis (MC)

Mechanism = pronation & wrist extension

TREATMENT
Treatment = conservative, steroids, vs. surgery
Repetitive motions
Conservative
MC = >40 years old
RICE

NSAIDs

SYMPTOMS & EXAM Diclofenac = topical gel

Activity modification
Lateral elbow pain
Occupational therapy = more helpful than PT
Worse = pronation, active & resistive wrist
Wrist splint = resting wrist is resting elbow tendon
extension, & passive wrist flexion
Counterforce bracing = tennis elbow strap

Pressure distally to change angle of pull on

tendon -> putting counterforce on tendon

Steroids = short-term benefit

Any steroid into tendon weakens tendon

Can put in UE tendon b/c they do not have as much

weight bearing or as much force as LE

Surgery = refractory to conservative & steroids

No improvement with 6-12 months

*DON'T FORGET*: TENNIS ELBOW

 MEDIAL EPICONDYLITIS

KEY INFORMATION
AKA Golfer's Elbow
MC = 40-60 years old

ETIOLOGY / PATHO DIAGNOSIS

Clinical diagnosis
Inflammation of tendon insertion of pronator

teres & flexor carpi radialis

MC = 40-60 years old

TREATMENT
Treatment = conservative, steroids, vs. surgery

SYMPTOMS & EXAM Conservative

RICE
Medial elbow pain
NSAIDs
Worse = active & resistive wrist flexion
Activity modification

Steroids = short-term benefit -> RARELY done

*DON'T FORGET*: GOLFER'S ELBOW

ULNAR COLLATERAL LIGAMENT INJURIES

KEY INFORMATION
Valgus force
Baseball player

ETIOLOGY / PATHO DIAGNOSIS

Mechanism= valgus force MRI = imaging of choice

Risk factor = overhead throwing (baseball) Special tests

Especially pitchers (+) valgus stress test = pain with vagus stress

Late cocking & early acceleration (+) milking maneuver = flex albow & supinate

Loss of velocity/accuracy wrist then pull thumb laterall

Feel for gaping or laxity over UCL

SYMPTOMS & EXAM

Medial elbow pain TREATMENT
Treatment = surgery

Conservative = NONE -> will not heal on own!

Surgery = Tommy John with ulnar nerve

transposition

*THINK ABOUT*: BASEBALL & ELBOW PAIN

BICEPS TENDON RUPTURE

KEY INFORMATION
MC =40-60 years old
(+) hook sign

ETIOLOGY / PATHO DIAGNOSIS

Ruptured distal biceps tendon Clinical diagnosis

MC = 40-60 years old MRI/US = surgical planning

Special tests

SYMPTOMS & EXAM (+) hook sign = hooking of biceps tendon

Pain & swelling

Ecchymosis TREATMENT
TTP at radial tuberosity Treatment = conservative vs. surgery

Popeye deformity = muscle retracted up into arm Conservative = very old OR surgery risks outweigh

benefits -> will be left with popeye deformity

Weakness with supination
Surgery = within 3 weeks

>3 weeks = muscle/tendon retracts & scars down

Endo-button with fibro-wire

*DON'T FORGET*: POPEYE DEFORMITY

CUBITAL TUNNEL SYNDROME

KEY INFORMATION
Ulnar nerve entrapment
(+) tinel sign

ETIOLOGY / PATHO DIAGNOSIS

Compression/entrapped ulnar nerve @ elbow EMG/NCS = not necessary, but diagnostic

At cubital tunnel along medial elbow Special tests

(+) tinel sign = reproducible pain with

SYMPTOMS & EXAM tapping ulnar nerve

(+) wartenburg test = when patient adducts

Burning & stinging = down into forearm
with palm on table, pinky “lags”
Numbness & tingling = down into forearm & wrist
Unopposed action of extensor
↓ sensation to 5th & ulnar side of 4th finger
(+) froment’s sign = patient uses thumb to

grab paper

If they flex their thumb, trying to use flexor

pollicis instead of adductor pollicis

TREATMENT
Treatment = conservative vs. surgery

Conservative = OT referral

Surgery = surgical decompression or transposition

*THINK ABOUT*: NUMBNESS/TINGLING AT ELBOW

 OLECRANON BURSITIS

KEY INFORMATION
BURSA inflammation or irritation
Don't forget -> could be infectious

ETIOLOGY / PATHO DIAGNOSIS

Inflamed or irritated bursa Clinical diagnosis

Etiologies Aspiration = evaluate for septic or gout

Trauma

Overuse = repetitive microtrauma TREATMENT

Gout Treatment = bursitis vs. septic bursitis

Infectious = staph aureus (MC) Bursitis = NSAIDs, elbow padding, & ACE wrap

Hemorrhage Septic bursitis = I&D and ABX

+/ – bursa excision = rare

SYMPTOMS & EXAM

Goose egg = boggy & swelling

Chronic = painless & full ROM

Infectious or inflammatory = painful ROM,

warmth, & erythema

*THINK ABOUT*: SWELLING AT ELBOW

RADIAL HEAD SUBLUXATION

KEY INFORMATION
MC = 2-5 years old
Annular ligament

ETIOLOGY / PATHO DIAGNOSIS

Radial head wedges into annular ligament Clinical diagnosis

Annular ligament slips over head of radius &

into radiohumeral joint TREATMENT

Mechanism = axial traction on pronated forearm Treatment = closed reduction

with elbow in extension Closed reduction = supinate & flex or hyperpronate

Swinging Observe child using arm after 15 minutes

Pulling

Lifting

SYMPTOMS & EXAM

Arm flexed at elbow & pronated

Child refuses to use arm

Tenderness to radial head (lateral elbow)

*THINK ABOUT*: CHILD WITH ELBOW PAIN

 RADIAL HEAD FRACTURE

KEY INFORMATION
Sail sign
Posterior fat pad

ETIOLOGY / PATHO DIAGNOSIS

Mechanism = FOOSH X-ray = best initial imaging

Anterior fat pad DISPLACED = sail sign

SYMPTOMS & EXAM Posterior fat pad PRESENT

Abnormal & more specific for fracture

Tenderness to lateral elbow

Inability to fully extend elbow

+/– effusion
TREATMENT
Treatment = acute vs. long-term

Acute = sling & posterior splint

Long-term = conservative & surgery

Conservative = sling & posterior splint

Splint <10-14 days

Surgery = ORIF

*BUZZ WORD*: SAIL SIGN

 MONTEGGIA FRACTURE

KEY INFORMATION
PROXIMAL ulnar fracture
“A” = bones affected proximally

ETIOLOGY / PATHO DIAGNOSIS

Proximal 1/3 ulnar shaft fracture + radial head X-ray = best initial imaging

dislocation

Mechanism = direct blow TREATMENT

Treatment = stable vs. unstable

SYMPTOMS & EXAM Stable = splint

Pain & swelling Unstable = ORIF

Thumb paresthesia Complications = wrist drop (radial nerve injury)

*THINK ABOUT*: MONTEGGIA ("A” IS PROXIMAL)

 GALEAZZI FRACTURE

KEY INFORMATION
MID-DISTAL radial shaft fracture
“Z” = bones affected distally

ETIOLOGY / PATHO DIAGNOSIS

Mid-distal radial shaft fracture + distal X-ray = best initial imaging

radioulnar joint dislocation

Mechanism = FOOSH TREATMENT

More common than Monteggia Treatment = stable vs. unstable

Stable = splint

SYMPTOMS & EXAM Unstable = ORIF

Pain & swelling Complications = anterior interosseous nerve injury

Deformity and compartment syndrome

Ulnar head appears prominent at wrist

*THINK ABOUT*: GALEAZZI ("Z” IS DISTAL)

GREENSTICK FRACTURE

KEY INFORMATION
Does not break through entire bone
High risk for repeat fracture

ETIOLOGY / PATHO DIAGNOSIS

Incomplete fracture through part of cortex X-ray = best initial imaging

Like fracturing young wood stick/ wood

Does not get break through entire bone TREATMENT

Pediatric bones are squishy & less calcified Treatment = depends on location & involvement

Immobilization followed by casting

SYMPTOMS & EXAM Complications = high risk for repeat fracture

Pain & swelling

Deformity

*THINK ABOUT*: PEDIATRIC FRACTURE

 T O R U S F R A C T U R E

KEY INFORMATION
AKA Buckle Fracture
Too high to be Salter Harris

ETIOLOGY / PATHO DIAGNOSIS

Bowing or bending deformation X-ray = best initial imaging

Pediatric bones are spongey & compress

Mechanism = axial loading TREATMENT

Too high to be Salter Harris Treatment = depends on location & involvement

SYMPTOMS & EXAM

Pain & swelling

Deformity

*THINK ABOUT*: PEDIATRIC FRACTURE

SALTER-HARRIS FRACTURE

KEY INFORMATION
Growth plates
5 types

ETIOLOGY / PATHO DIAGNOSIS

Where they lie in relation to growth plates X-ray = best initial imaging

ONLY applies to open growth plates Type 1 = can’t see anything on x-ray because

Epiphysis vs. metaphysis growth plates are black on x-ray

Epiphysis = end part of a long bone Commonly missed injuries

Metaphysis = wide portions of long bones
REPEAT = calcification (bone healing)
physis = growth plate = epiphyseal plate
Type 5 = crushed black growth plate
Salter-Harris classification

TREATMENT
Type 1 = growth plate only

Type 2 = fracture above epiphyseal plate

Treatment = depends on type
Type 3 = below growth plate

Type 4 = through growth plate Prognosis

Type 5 = crush Type 1 = good

Mnemonic Type 2 = good** -> MC type of SH fracture!!

S = slipped Type 3 = poor (often unstable)

A = above Type 4 = poor

L = lower Prone to limb length discrepancies

T = through
Type 5 = worst
(e)
Prone to limb length discrepancies
R = raised

SYMPTOMS & EXAM

Pain & swelling

Deformity

*THINK ABOUT*: GROWTH PLATES

 SCAPHOID FRACTURE

KEY INFORMATION
Snuff box
Thumb spica

ETIOLOGY / PATHO DIAGNOSIS

Mechanism = FOOSH with wrist extension X-ray = (AP, lateral, & oblique) = initial imaging

Location = anatomical snuff box Scaphoid views = zoom in on scaphoid

MC fractured carpal bone May not show up on initial films

Repeat films in 1 week

SYMPTOMS & EXAM Bone scan, CT or MRI = more sensitive

Onset = sharp pain

Later = dull & achy pain

TREATMENT
Treatment = acute vs. long-term
TPP in snuffbox
Acute = thumb spica
Palpable crepitus
Non-displaced or snuff box tenderness
Pain with passive radial deviation
Long-term = conservative & surgery (ortho referral)
Pain with axial loading of thumb
Conservative = thumb spica & bone stimulator

Surgery = screw or pin +/ – bone graft

Complications = avascular necrosis of scaphoid

Poor blood supply = “watershed area”

Non-union = non-healing

More distal = more likely to heal

Better blood supply

*BUZZ WORD*: SNUFF BOX

 OSTEOGENESIS IMPERFECTA

KEY INFORMATION
AKA "brittle bone disease"
Spontaneous fractures

ETIOLOGY / PATHO DIAGNOSIS

Genetic defect of type 1 collagen Clinical diagnosis

Autosomal dominant X-ray = osteopenia

AKA "brittle bone disease" Genetic testing = definitive diagnosis

SYMPTOMS & EXAM TREATMENT

Osteoporosis = severe & premature Treatment = meds, PT, or surgery

Spontaneous fractures Meds = bisphosphonates

Limb deformities & shortening -> increased laxity Physical therapy

Blue sclera Surgery = fractures

Easily bruise Complications = fetal or perinatal death & IUGR

Hearing loss = presenile

*THINK ABOUT*: FRACTURES & HEARING LOSS

 C O L L E S F R A C T U R E

KEY INFORMATION
Distal radial fracture
DORSAL displacement

ETIOLOGY / PATHO DIAGNOSIS

Distal radial fracture w/ DORSAL displacement X-ray = best initial imaging -> need lateral view

Mechanism = FOOSH with wrist extension

TREATMENT
SYMPTOMS & EXAM Treatment = acute vs. long-term

Acute = short arm cast (sugar-tong splint)

Wrist pain
Control supination & pronation
Worse = passive motion
Long-term = conservative & surgery
Dinner fork deformity
Conservative = short arm cast

Surgery = ORIF

Complications = extensor pollicis longus tendon

rupture, malunion, nonunion, joint stiffness, median

nerve compression, residual radius shortening, &

complex regional pain syndrome

*BUZZ WORD*: DINNER FORK DEFORMITY

 S M I T H F R A C T U R E

KEY INFORMATION
Distal radial fracture
VOLAR displacement

ETIOLOGY / PATHO DIAGNOSIS

Distal radial fracture w/ VOLAR displacement X-ray = best initial imaging -> need lateral view

Mechanism = FOOSH with wrist flexion

TREATMENT
SYMPTOMS & EXAM Treatment = acute vs. long-term

Acute = short arm cast (sugar-tong splint)

Wrist pain
Control supination & pronation
Worse = passive motion
Long-term = conservative & surgery
Garden spade deformity
Conservative = short arm cast

Surgery = ORIF

*BUZZ WORD*: GARDEN SPADE DEFORMITY

L U N A T E D I S L O C A T I O N

KEY INFORMATION
“piece of pie” & “spilled teacup”
ORTHOPEDIC EMERGENCY

ETIOLOGY / PATHO DIAGNOSIS

X-ray = best initial imaging
Lunate not articulating with capitate & radius
“piece of pie” = lunate appears triangular
Lunate occupies 2/3 of radial articular surface
"spilled teacup” = volar displaced & tilt of lunate

SYMPTOMS & EXAM

Pain & swelling TREATMENT
Median nerve symptoms Treatment = acute vs. long-term

Palmar aspect of first 3 + ½ of 4th digits Acute = closed reduction & splint

Long-term = ORIF

Complications = evaluate for lunate dislocation

which can lead to Kienbock’s disease

*BUZZ WORD*: KIENBOCK’S DISEASE

K I E N B O C K ’ S D I S E A S E

KEY INFORMATION
Avascular necrosis of lunate
Ulnar negative variance

ETIOLOGY / PATHO DIAGNOSIS

X-ray = increased denisty of lunate
Avascular necrosis of lunate
Ulna negative variance = shorter
Leads to progressive collapse
Bone scan & MRI = more sensitive
Etiology = unknown

Disruption of blood supply?

Undiagnosed fracture?
TREATMENT
Treatment = conservative vs. surgery
Repetitive trauma
Conservative = immobilization

SYMPTOMS & EXAM Surgery = late presentation or severe

Radial shortening osteotomy

Swelling & stiffness
Vascularized bone graft
Crepitus
Proximal row carpectomy
↓ ROM
Wrist arthrodesis = joint fusion
Weakness with grip

TTP over lunate

Effusion

*THINK ABOUT*: LUNATE FRACTURE/DISLOCATION

MALLET (BASEBALL) FINGER

KEY INFORMATION
Sudden FLEXION
Extensor tendon

ETIOLOGY / PATHO DIAGNOSIS

X-ray (AP, lateral, & oblique) = initial imaging
Injury to extensor tendon @ dorsal DIP joint
Finger specific = not just hand x-rays
May be tendon rupture

May be avulsion fracture

Mechanism = sudden flexion of DIP TREATMENT

Volleyball Treatment = soft tissue vs. bony (fracture)

Basketball Soft tissue = 6-8 weeks of extension splinting

May initiate within 3 months of injury

SYMPTOMS & EXAM DO NOT immobilize PIP joint

Bony (fracture) = K-wire fixation

Pain & swelling = dorsal aspect
Fracture fragment > 50% articular surface
Ecchymosis
Dislocation with fracture
Flexion deformity & extensor lag at DIP

TTP at distal finger = DIP

Pain with motion

*THINK ABOUT*: FLEXION, DIP JOINT & EXTENSOR

 J E R S E Y F I N G E R

KEY INFORMATION
Sudden EXTENSION
Flexor tendon

ETIOLOGY / PATHO DIAGNOSIS

X-ray (AP, lateral, & oblique) = initial imaging
Injury to flexor tendon @ volar DIP joint
Finger specific = not just hand x-rays
May be tendon rupture

May be avulsion fracture

FDP = flexor digitorum profundus TREATMENT

Mechanism = sudden hyperextension of DIP Treatment = conservative vs. surgery

during active flexion Conservative = not usually an option

Caught in shirt/jersey Surgery = ALL jersey fingers require surgery!

Football Primary tendon repair

Fracture fragment repair

Ring finger = MC

SYMPTOMS & EXAM

Pain & swelling = volar aspect

Ecchymosis

Flexion deformity at DIP -> CANNOT flex DIP

TTP at distal finger = DIP

Pain with motion

Lump in palm = tendon balled up

Tendon retracts back into palm

Lump is their tendon

Retracts because tension pulling it back

Flexor tendons = stronger & deeper

Compared to extensor tendons

*THINK ABOUT*: EXTENSION, DIP JOINT & FLEXOR

DE QUERVAIN TENOSYNOVITIS

KEY INFORMATION
MC = women 30-50 years old & new moms
Thumb spica

ETIOLOGY / PATHO DIAGNOSIS

Clinical diagnosis = no imaging needed
Entrapment tendinitis of lateral wrist
Special tests
1st dorsal extensor compartment
(+) finkelstein test = pain with ulnar deviation
Abductor pollicis longus
while thumb flexed in palm
Extensor pollicis brevis

Mechanism = repetitive lifting & thumb use

Golfers
TREATMENT
Treatment = conservative, steroids, or surgery
Clerical workers
Conservative = 6-8 weeks of extension splinting
Postpartum = lifting newborn
RICE
Diabetes
NSAIDs
MC = women 30-50 years old & new moms
Thumb spica splint

SYMPTOMS & EXAM PT/OT referral

Steroids (injections) = refractory to conservative

Pain & swelling @ radial side of wrist
Surgery = refractory to nonoperative
Worse = thumb extension

TTP radial wrist & base of thumb

“Snowball crepitus” = like snowball crunching

*THINK ABOUT*: NEW MOM WITH WRIST PAIN

 T R I G G E R F I N G E R

KEY INFORMATION
MC = 2nd, 3rd, & 4th fingers
Surgery does NOT work well in diabetes

ETIOLOGY / PATHO DIAGNOSIS

Clinical diagnosis = no imaging needed
Stenosing flexor tenosynovitis

Thickened “pulley”/ thickened sheath

Etiologies = overuse or injury

TREATMENT
Treatment = conservative, steroids, vs. surgery
MC = 2nd, 3rd, & 4th fingers
Conservative

SYMPTOMS & EXAM NSAIDs

Bracing = trigger finger brace

Pain = worse in AM & PM
Steroids = short-term benefit
Palpable nodule = thickened “pulley”
Persistent relief >1 year in 50% of patients
Finger gets “stuck”
Other 50% may need 2nd injection

Surgery = surgical release

98% effective -> EXCEPT in diabetics!

Not as effective in diabetics

*THINK ABOUT*: FINGER GETS STUCK

F I N G E R D I S L O C A T I O N

KEY INFORMATION
DIP > PIP > MCP
Dorsal > volar

ETIOLOGY / PATHO DIAGNOSIS

X-rays (AP, lateral, & oblique) = initial imaging
Loss of joint continuity
Finger specific = not just hand x-rays
DIP > PIP > MCP
Rule out fracture before reduction!
Dorsal > volar

Mechanism

Hyperflexion
TREATMENT
Hyperextension Treatment = reduction & splint

Lateral force Reduction = with or w/o anesthetic (digital block)

Traction = no recreation -> right into traction

Medial force
“Re-create injury” then traction
Axial load
Splint

SYMPTOMS & EXAM Lateral/medial = buddy tape -> follow-up prn

Dorsal = splint -> need ortho follow-up

Pain & loss of ROM
Volar = splint -> need ortho follow-up
Deformity
Contraindications to reduction

Open dislocation

Associated fracture

Digital N/V compromise

Inability to reduce

*DON'T FORGET*: BUDDY TAPE

GAMEKEEPER’S & SKIER’S THUMB

KEY INFORMATION
Skier's = acute
Gamekeeper's = chronic/overuse

ETIOLOGY / PATHO DIAGNOSIS

Injury to thumb ulnar collateral ligament (UCL) X-rays = best initial imaging

Base of proximal phalanx at 1st MCP Do not stress MCP joint prior to X-rays!

Forced abduction Must rule out fracture first

Mechanism = valgus & hyperextension Do not want to displace bony fragment

Skier
Special tests
Football
(+) valgus stress test = increased laxity
FOOSH
Stress x-ray = PE equivocal & standard x-ray (–)
Classifications
MRI = increased signal if tear present
Partial or complete tear

+/– fracture = proximal phalanx fracture

Acute or chronic TREATMENT

Types Treatment = acute vs. long-term

Skier’s thumb = acute Acute = thumb spica & ortho referral

Gamekeeper’s thumb = chronic / overuse Long-term

Partial tear or non-displaced fracture = cast/splint

SYMPTOMS & EXAM Complete tear or displaced fracture = surgery

Pain & swelling = 1st MCP

“Jammed thumb”

Ecchymosis @ thenar eminence

Valgus stress causes >35-degree laxity

Painful ROM

Weak pincer grip

*DON'T FORGET*: THUMB SPICA

 B O X E R ’ S F R A C T U R E

KEY INFORMATION
Patient could have bite wound
Ulnar gutter splint

ETIOLOGY / PATHO DIAGNOSIS

Fracture at neck of 4th & 5th metacarpal X-rays (AP, lateral, & oblique) = initial imaging

Mechanism = punching wall or face

TREATMENT
SYMPTOMS & EXAM Treatment = conservative vs. surgery
Pain & swelling
Conservative = ulnar gutter splint
LOOK FOR BITE WOUNDS!!
Surgery = severe
Might hit tooth when punching
ABX = bite wound (Augmentin)

*DON'T FORGET*: TREAT BITE WOUND WITH ABX

CARPAL TUNNEL SYNDROME

KEY INFORMATION
Median nerve
Volar splint/bracing = conservative tx

ETIOLOGY / PATHO DIAGNOSIS

No imaging needed
Median nerve entrapment & compression
EMG/NCS = diagnosis is not clear / confirm
Risk factors
Cervical radiculopathy or thoracic outlet??
Women Make sure it is just locally at wrist!

DM Special tests

Pregnancy (+) carpal compression test = pressure on median

nerve reproduces symptoms

Hypothyroidism
(+) tinel test = percussion of median nerve reproduces
Rheumatoid arthritis
symptoms
Overweight / obese (+) phalen test = flexion of both wrists reproduces

symptoms

SYMPTOMS & EXAM

Pain & paresthesia
TREATMENT
Treatment = conservative, steroids or surgery
Palmar aspect of first 3 + ½ of 4th digits
Conservative
Worse = night, driving, & repetitive activities Volar splint / brace = help if waiting for surgery
NSAIDs
Clumsiness with hand
Avoid repetitive movements / activity restriction
Thenar muscle wasting = advanced disease PT & OT = improve function & strength

Short term = numbness & tingling in fingers Nerve gliding

Therapeutic ultrasound
Long term = nerve damage & muscle weakness
Steroids (injections) = refractory to conservative
Methylprednisolone = 40 mg vs. 80 mg
80% get relief initially
+/– no more than 2x per year
Surgery = refractory to nonoperative
Open or endoscopic = cutting flexor retinaculum
Earlier return to work & activity with endoscopic
No difference in long-term outcomes

*DON'T FORGET*: MEDIAN NERVE ENTRAPMENT

BENNET & ROLANDO FRACTURE

KEY INFORMATION
Bennet = non-comminuted
Rolando = comminuted

ETIOLOGY / PATHO DIAGNOSIS

X-ray = best initial imaging
Metacarpal fracture of base of thumb
Bennet = small fragment of thumb base
Mechanism = axial force to flexed thumb
Rolando (Y-sign) = splitting of thumb base
Bennet = non-comminuted

Rolando = comminuted
TREATMENT
SYMPTOMS & EXAM Treatment = conservative vs. surgery

Pain & swelling Conservative = thumb spica splint

Ecchymosis Surgery = closed reduction with pinning & ORIF

TTP of CMC joint = base of thumb

*DON'T FORGET*: THUMB SPICA

 DUPUYTREN CONTRACTURE

KEY INFORMATION
UNABLE to straighten finger
Fibrosis of palmar fascia

ETIOLOGY / PATHO DIAGNOSIS

Clinical diagnosis
Fibrosis of palmar fascia

Leads to contracture from nodules or cords

Risk factors TREATMENT

Men
Treatment = conservative, injections, or surgery
>40 years age
Conservative = physical therapy
EtOH
Injections = intralesional collagenase or steroids
Cirrhosis
Surgery = advanced stages, impaired function, or
Diabetes mellitus
refractory cases
Smoking

SYMPTOMS & EXAM

Nodules over distal palmar crease

Thickened skin

Bands in palmar fascia

Fixed flexion deformity at MCP

UNABLE to straighten finger!

*THINK ABOUT*: NODULE & CAN'T STRAIGHTEN FINGER