“Don’t-Miss” Musculoskeletal Injuries (Quiz time!)

1. “Don’t-Miss” Musculoskeletal Injuries(Quiz time!) MS3 Family Medicine

2. Goals Review injuries you don’t want to miss while an MS3 Shoulder Back Knee Leg/Ankle/Foot Review lessons learned in lectures

3. The 6-step msk exam steps are… • Inspection • Palpation • Range of motion • Strength • Neurovascular • Special Tests

4. 15 year old lacrosse player is struck in the arm while running Holds arm at his side Has pain with any movement of the arm Suspect dislocation

5. Which aspect of examination is particularly important early on? Inspection Palpation Range of motion Strength Neurovascular Special tests

6. Which xray view is needed to determine direction of dislocations? AP chest Glenohumeral AP Scapular Y Axillary

7. Anterior or posterior?

8. Which is NOT a common mechanism for posterior shoulder dislocation? Arm is hit while throwing Electrocution Fall on outstretched hand Seizures 10

9. SITS in the rotator cuff muscles stands for… • Supraspinatus • Infraspinatus • Teres minor • Subscapularis

10. Poor motion Poor strength Pain worse while lying on side ADLs affected Normal appearance NTTP ROM: poor active abduction, better passive Strength: poor abduction N-V: normal Tests: + Hawkins & Neers + empty can + drop-arm A 35 yo male falls off a 4-foot ladder onto his elbow 1 week ago and c/o shoulder pain

11. What’s your diagnosis? • AC sprain • Humeral head fracture • Impingement syndrome • Rotator cuff tear

12. Treatment • Analgesics • Physical therapy referral • Improve ROM, strength • Orthopedics consult if poor improvement • ? repair

13. 18 year old Marine Corps Corporal twisted ankle during morning run… Patient cannot put weight upon the leg. Pain is located anteriorly above the ankle joint, & laterally Lateral edema Neg drawer/tilt tests Positive Squeeze Test Positive External Rotation Stress Test

14. Should you get an xray? • Yes • No • Don’t know

15. What finding on xray would prompt referral for surgery? Widened mortise Fibular avulsion fracture Soft tissue swelling

16. High Ankle SprainAKA Pain proximal to ankle Painful ExtRot test Painful squeeze test ORDER xrays Rule out mortise widening Rule out fractured proximal fibula Treatment: Wide mortise: SURGERY Normal xrays: cast 2-4 weeks >5mm

17. In inversion ankle sprains, which feature is not an indicator for an xray? • Tenderness over the ATFL • TTP over the navicular bone • TTP over the 5th MT base • Inability to bear weight

18. Ottawa Ankle RulesWhen to x-ray acute ankle sprains Unable to bear weight Tender over posterior lateral malleolus Tender over posterior medial malleolus Tender on navicular bone Tender on 5th MT base

19. 20 year old female soccer player Going for a ball on the sideline Plants her foot to kick the ball and is struck by another player on the lateral side of the knee Collapses, but is able to get up and play Has significant medial knee pain by end of game No effusion, but develops an effusion by next morning Can’t bend knee much

20. Differential Diagnosis ACL rupture PCL rupture Patellar subluxation Tibial plateau fracture Medial collateral ligament strain Meniscal tear “Terrible Triad”

21. Which finding might prompt an xray per Ottawa knee rules? • Age of 20 • Inability to bend knee >90d • Hx of trauma • Effusion

22. 5 Ottawa Knee Rulesi.e. When to order a knee xray after acute injury Age > 55 or < 18 Unable to walk TTP on PATELLA TTP on FIBULAR HEAD Unable to flex 90 deg

23. Physical Examination • Effusion, no deformity • TTP over ant-med joint line • ROM: slight restriction of flexion • Strength: can’t test • N-V: normal • Special tests: • Positive Thessaly • Positive McMurray • Negative Lachman, posterior drawer, varus & valgus stress, patellar apprehension, etc.

24. What’s your diagnosis? • Tibial plateau fracture • ACL tear • Patellofemoral syndrome • Meniscal tear

25. Meniscal Tear Often due to varus or valgus stress May be associated with collateral ligament strain and/or ACL rupture Radial, longitudinal, horizontal or bucket handle

26. History “Twisting on a slightly flexed knee” Effusion comes on gradually over 24 hours May have locking, catching, or popping Traumatic in young, degenerative in older patients

27. Management Watch/wait if ADLs do not bother the patient Consider MRI Referral for Surgery indicated for pain with ADLs Locking Large effusion Repair vs debridement “Red zone vs white zone”

28. A 35 yo runner training for a 10k c/o anterolateral knee pain, worse w/ running or prolonged sitting, no h/o trauma. Exam: + patellar grind, neg apprehension. Diagnosis? • Plica syndrome • ITB syndrome • MCL sprain • Patellofemoral syndrome

29. Reduce painful activities Non-painful aerobics Patellar retinaculum stretching Hamstring stretching Quad strengthening (VMO) Eval for hyperpronation Hip abductor strengthening (Physical therapy) Consider knee sleeve PFS Treatments

30. Back Pain 42 year old pilot presents with LBP Past medical history significant for chronic low back pain Denies any recent trauma

31. He has these additional historical features. Which of them is a “red flag”? • Pain radiating below knee • Pain worse with sitting • Numbness in left foot • Recent fevers

32. Examination • Inspection: antalgic gait; normal pelvis and back • Palp: TTP over midline L5 level • ROM: marked decrease flex/ext • Strength: decreased • N-V: • Decreased sensation right dorsum foot • DTR’s normal • Weak dorsiflexion of right ankle • Special: • Positive SLR on right

33. At what neural level do you suspect a deficit? L3 L4 L5 S1 S2

34. Differential Diagnosis Herniated disk Urinary tract infection Prostatitis STD Osteomyelitis Epidural abscess Tumor

35. Imaging Plain films neg Anything else? MRI Epidural abscess L4-5

36. Treatment IV antibiotics Orthopedic or neurosurgical consultation

37. Which is NOT a “red flag” in LBP? • Age > 50 • History of cancer • History of major trauma • Recent fevers • Saddle anesthesia • Urinary retention • Sciatica

38. During Ultimate Frisbee, a USUHS student planted her foot, someone stepped on her heel, a loud audible pop is heard and she is unable to bear weight. She develops severe pain and swelling on top of the mid-foot. • Examination shows swelling in the midfoot • Midfoot palpation and stress test is OUCH • Ankle ROM relatively normal • Toes weak from pain in foot

39. What type of xrays should you order? • Tib-fib, ankle and foot • AP/lateral foot • Weight-bearing foot series

41. What should concern you on xrays of midfoot sprains? • Stepoffs between bones on lateral view • Widening between 1st/2nd MT bases • Discontinuity between MTs and cuneiforms • Any of the above

42. Lisfranc Complex Injury • 20% are missed on initial presentation • Treatment • Casting 2-6 weeks if NO FRACTURES OR INSTABILITY • Surgery for fractures or instability • CT/MRI/Bone Scan

43. A medical student is thinking about going into Family Medicine because Sports Medicine is so awesome! Who should he/she talk to? • Dr. Phil • Aunt Lucy • Santa Claus • Dr. Kevin deWeber in Rm A1033, or at 301-295-9466

44. QUESTIONS?