Clin Med III: Musculoskeletal - Knee, Shoulder, and Wrist

knee

femur, tibia, and patella
tibiofemoral and patellofemoral

False: The knee is an inherently INSTABLE joint.

1. flexion-extension
2. varus-valgus
3. external-internal rotation
4. anterior-posterior translation (glide)

prevent excessive valgus and varus displacement

1. acts as a linkage between the posterior cortex of the femur and the posterior cortex of the tibia
2. prevents posterior displacement of the tibia on the femur

1. prevents anterior displacement of the tibia on the femur
2. prevents excessive internal rotation movement of the tibia on the femur

increased synovial fluid production due to synovial tissue irritation

a sesmoid bone

the patella

True

fracture or ligamentous disruption

False: damage is generally not apparent until several hours after injury

extensive internal derangement

with internal rotation of the knee

the medial collateral ligament

force directed at the lateral aspect of the knee

between the tibia and the insertion of the pes anesrine aponeurosis

lateral collateral ligament

False: It rarely interferes with extension.

MC - torn meniscus
other causes - osteochondral fracture that is detached; large tibial remnant of a torn ACL

injury to ligamentous stabilizers (ACL and PCL)

tibial plateau fractures
medial collateral ligament sprains
meniscus tears

ligamentous injury

>55 years of <12 years
blunt trauma or fall
tenderness at head of fibula
isolated tenderness of patella
inability to flex knee to 90 degrees
inability to walk four weight bearing steps

torn ligament
torn tendon
fracture
torn meniscus

True. Most resolve spontaneously

medial collateral ligament injuries

medial collateral ligament injury

involvement of PCL in addition to MCL

Grade III
examine pt closely for signs of concomitiant ACL tear for which surgery would mor elikely be done

micro-tears of the ligament and correspond to <5mm in increased joint opening and no instability

partial macro-tear of the ligament wand presence of instability and significant increased joint opening with an end point

twisting knee injury or hyperextension knee injury and subsequent effusion

hemarthrosis

Lachman test, anterior drawer, pivot shift test, varus and valgus stress

OA often develops

direct trauma to the proximal tibia when the flexed knee is decelerated rapidly as in a DASHBOARD injury

posterior drawer test

isolated tears - conservative treatment with PT and quadricaps strengthening

False: medial is more common than lateral

pain at the time of injury which persists and interferes with weight-bearing activity

the outer 1/3
bleeding occurs but at a much slower rate than with ACL tear
- minor swelling at time of injury, but more pronounced when arising in the a.m.`

tenderness along the joint line
often complain of knee locking

with anterior knee pain, which is worse after prolonged sitting with the knee flexed, or on climbing or descending stairs or slopes

pain may be reproduced by palpating the patellar facets
grind test

NSAIDS, strengthening the vastus medialis oblique and hamstring stretching

after 3 dislocations

overuse syndrome that occurs between the ages of 10-15years old and is more common in boys

fragmentation of the tibial tubercle

pain in posterior calf
tenderness over distal achilles tendon which may be acompanied by boggy swollen mass

small heel pad or lift temporarily

palpable defect and a positive Thompson's squeeze test

inversion sprains

True

neuroma that occurs on the 3rd plantar interdigital nerve

corticosteroid injection with a local anesthetic

with the first couple steps in the morning or after prolonged standing or walking

False: Injection of local anesthetic without a corticosteroid is often effective.

compression of the posterior tibial nerve within the canal caused by synovitis of the flexor tends of the ankle due to abnormal foot function or inflammatory arthritis or venous stasis edema

distal tingling when tapping or palpating the posterior tibial nerve below the medial malleolus

determining the etiology

rotator cuff overuse
repetitive movements with arms overhead

supraspinatus

progressive pain
pain as acromion encroaches on rotator cuff
worsens with specific activities (reaching forward or overhead)
move severe at night (laying on affected side)
painful arc (moving arm through 60-120 degree abduction)
unable to pinpoint onset

False: usually have no history of trauma

to the proximal, lateral arm

MRI

rest, sling
NSAIDS, corticosteroid injections
moist heat, PT

when patients fail conservative treatment

abduction or flexion of the shoulder

hindered abduction
weakness when are in rotated internally at 90 degrees of abduction
positive "drop arm" sign

chronic tendonitis and bursitis

sudden, tearing, sharp pain which may radiate to elbow
muscle spasms may be present
point tenderness

x-ray +/- elevation of humeral head

rotator cuff tear

analgesia, immobilization, prompt orthopedic follow-up

3 weeks

a chronic rotator cuff tear

adhesive capsulitis

loss of range of motion

women more than men
age 40-60
in the nondominant arm

diabetes, hypothyroidism, and even mental illness

NSAIDS
intra-articular steroid injections
physical therapy

posterior dislocation

polymalgia rheumatica occurs in both shoulders, elevated ESR

supraspinatus muscle

silent, subacute, acute

incidentally on x-ray
deposits are well defined with NO inflammation

pain and limited ROM
sharp-edged, noninflammatory deposits
cloudy, more transparent deposits

x-ray finding resemble an abscess, cloudy edges with inflammation
shoulder is warm and tender

AP view of shoulder in internal and external rotation

resolves spontaneously within a few weeks
immobilization
NSAIDS
Acute phase - intraarticular injection of lidocaine and a steroid
gentle ROM exercises to prevent frozen shoulder

tendon of long head of biceps

inflammation of the tendon of the long head of the biceps as it traverses the bicipital groove of the humerusl

pain on the anterior shoulder
test with arm adducted and elbow flexed, wrist supinated
- examiner attemps to extend elbow and pronate wrist

pain in the lateral shoulder

pushing off the wall
winging of the scapula; paralysis of long thoracic nerve

resistance to abduction with arm at 90 degress and thumb pointing down
forward flexion 30 degrees

external rotation strength with arm at side and elbow flexed to 90 degrees

internal rotation strength with arm at side and elbow flexed to 90 degrees
lift off test

pain with passive elevation of the arm

arm elevated to 90 degrees with slight adduction, examiner internally rotates arm

forced radial abduction at the MCP joint
injury to the ulnar collateral ligament

thumb spica for partial
surgery for complete

from the scapholunate joint

from distal aspect of the radius

most do not require treatment and spontaneously regress
aspiration, with or without injection of a corticosteroid
surgical removal

compression of the median nerve

RA, DM, hypothyroidism, acromegaly, amyloidosis, and pregnancy, repetitive flexion and extension, idiopathic

pain of the hand and wrist associated with tingling and numbness along median nerve distribution
pain at night with burning or aching pain, numbness or tingling

Tinel's sign (tap and causes shooting pain)
Phalen's sign (hold wrists together for 90 seconds and causes pain)

wrist splint, vitamin b6, NSAIDS, corticosteroid injection, surgical decompression

injury resulting from forced flexion of the distal finger

splint finger in extension across DIP joint, leaving PIP joint free for 6-12 weeks

lacerations, dislocations, fracture, OA, or RA

Palmar fibromatosis
progressive contracture of the palmar fascial bands, producing flexion deformities of the fingers

autosomal dominant condition occurs more comming in patients with DM, alcoholism, or epilepsy

tender nodule in palm, most often at 3rd or 4th fingers, followed by formation of a superficial pretendinous cord, which leads to contracture of the MCP joints and IP joints

local injection of corticosteroids if during the early phase
surgical correction

tendosynovitis of the short extensor and long abductor tendon of the thumb
repetitive use of wrist
occasionally associated with RA
aching pain at the wrist and thumb, aggravated by motion

aching pain at the wrist and thumb, aggravated by motion
tenderness distal to the radial styloid process over the site of the involved tendon sheaths

Finkelstein test

rest, warm soaks
NSAIDS, thumb spica
local corticosteroid intrasynovial injections

tendon rupture - caution not to inject the tendon

overuse
caused by continued stress on the grasping muscles and supination muscles of the forearm, which originates on the lateral epicondyle of the elbow

pain at the site of tendon insertion
pain along lateral epicondyle when patient hits a backhand shot
pain may become constant and can refer to the wrist
pain with shaking hands and opening a jar

elbow held straight, fingers extended against resistance, pain occurs along the common extensor tendon

rest, ice, stretching, strengthening exercises, avoid painful movement

caused by forceful wrist flexion and pronation, damages the tendons that attch to the medial epicondyle

pain in the flexor pronator tendons when the wrist is flexed or pronated against resistance or when a hard rubber ball is squeezed

forearm resting on a table, hand supinated. patient tries to raise the fist by bending the wrist while the examiner holds it down

avoid activities that cause pain, strengthening exercises, surgery as a last resort

acute or chronic inflammation of a bursa

shoulder, olecranon, prepatellar, retrocalcaneal, greater trochanteric

trauma, chronic overuse, inflammatory arthritis (gout, RA), or infections

pain, localized tenderness, and limited motion

may follow previous attacks or repeated trauma

osteomyelitis, cellulitis

infection under the nail fold

warm soaks, antistaphylococcal antibiotics
I&D

infection of the digital pulp

I&D
antistaphylococcal antibiotics