1
Dont-Miss Musculoskeletal Injuries(Quiz
time!)

• MS3 Family Medicine

2
Goals

• Review injuries you dont 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?

1. Inspection
2. Palpation
3. Range of motion
4. Strength
5. Neurovascular
6. Special tests

6
Which xray view is needed to determine direction
of dislocations?

1. AP chest
2. Glenohumeral AP
3. Scapular Y
4. Axillary

7
Anterior or posterior?
8
Which is NOT a common mechanism for posterior
shoulder dislocation?

1. Arm is hit while throwing
2. Electrocution
3. Fall on outstretched hand
4. Seizures

9
SITS in the rotator cuff muscles stands for

• Supraspinatus
• Infraspinatus
• Teres minor
• Subscapularis

10
A 35 yo male falls off a 4-foot ladder onto his
elbow 1 week ago and c/o shoulder pain

• Normal appearance
• NTTP
• ROM poor active abduction, better passive
• Strength poor abduction
• N-V normal
• Tests
• Hawkins Neers
• empty can
• drop-arm

• Poor motion
• Poor strength
• Pain worse while lying on side
• ADLs affected

11
Whats your diagnosis?

1. AC sprain
2. Humeral head fracture
3. Impingement syndrome
4. 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?

1. Yes
2. No
3. Dont know

15
What finding on xray would prompt referral for
surgery?

1. Widened mortise
2. Fibular avulsion fracture
3. 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

gt5mm
17
In inversion ankle sprains, which feature is not
an indicator for an xray?

1. Tenderness over the ATFL
2. TTP over the navicular bone
3. TTP over the 5th MT base
4. 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
• Cant 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?

1. Age of 20
2. Inability to bend knee gt90d
3. Hx of trauma
4. Effusion

22
5 Ottawa Knee Rulesi.e. When to order a knee
xray after acute injury

• Age gt 55 or lt 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 cant test
• N-V normal
• Special tests
• Positive Thessaly
• Positive McMurray
• Negative Lachman, posterior drawer, varus
  valgus stress, patellar apprehension, etc.

24
Whats your diagnosis?

1. Tibial plateau fracture
2. ACL tear
3. Patellofemoral syndrome
4. 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?

1. Plica syndrome
2. ITB syndrome
3. MCL sprain
4. Patellofemoral syndrome

29
PFS Treatments

• 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

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?

1. Pain radiating below knee
2. Pain worse with sitting
3. Numbness in left foot
4. 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
• DTRs normal
• Weak dorsiflexion of right ankle
• Special
• Positive SLR on right

33
At what neural level do you suspect a deficit?

1. L3
2. L4
3. L5
4. S1
5. 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?

1. Age gt 50
2. History of cancer
3. History of major trauma
4. Recent fevers
5. Saddle anesthesia
6. Urinary retention
7. 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?

1. Tib-fib, ankle and foot
2. AP/lateral foot
3. Weight-bearing foot series

40
(No Transcript)
41
What should concern you on xrays of midfoot
sprains?

1. Stepoffs between bones on lateral view
2. Widening between 1st/2nd MT bases
3. Discontinuity between MTs and cuneiforms
4. 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?

1. Dr. Phil
2. Aunt Lucy
3. Santa Claus
4. Dr. Kevin deWeber in Rm A1033, or at 301-295-9466

44
QUESTIONS?