Musculoskeletal Diagnoses

Not To Be Missed

Bradford H. Stiles, MD, FAAFP

Disclosures

• I have a horrible deep sea fishing addiction

• My golf handicap is my swing

• No financial disclosures

What not to miss

• Scaphoid fracture

• Scapholunate dissociation

• Skier’s thumb

• Jersey finger

• Central slip rupture

• Little Leaguer’s elbow

• Distal biceps rupture

• Pectoralis major tear

• Complete rotator cuff tear

• SCFE

• Legg-Calve-Perthes

• Patella/Quad tendon tear

• Osteochondritis dessicans

• Achilles tendon rupture

• Lisfranc injury

• Jones fracture

• Cauda equina syndrome

Scaphoid fractures

� Most commonly fractured carpal

bone

� MOI: FOOSH injury (also assoc

w/distal radius, lunate and radial

head fxs)

� 3 zones: distal pole, waist,

proximal pole

� Waist: 80%, proximal pole: 15%,

distal pole: 5%

� Tenuous blood supply from distal

end only

� High incidence of non-union &

AVN in more proximal fractures

Presentation/exam

• Classic history

• May not have any swelling

• Tenderness at anatomic

snuffbox

• Positive axial load test of

1st MC

• Pain with

flexion/extension

Normal radiographs

Radiographs

• PA, lateral, oblique

(standard) and scaphoid

views

• Negative initial x-ray

doesn’t rule out a fx

• Rule of thumb: if positive

hx/MOI and snuffbox

TTP, treat as fracture, re-

image in 7-10 days

Treatment• Nondisplaced middle/proximal third fxs immobilized in long arm

thumb spica cast; distal third ND fxs may be immobilized in short arm

thumb spica cast

– Distal 1/3 fxs � 4-6 weeks

– Middle 1/3 and waist fxs � 10-12 weeks (may change to short arm thumb

spica cast after 6 weeks)

– Proximal 1/3 fxs � 12 -20 weeks

• May consider ORIF for proximal 1/3 fractures

• All displaced fractures need Ortho referral

• Risk of proximal AVN & severe radiocarpal OA if not treated properly

Scapholunate dissociation

• Most common ligament injury of the wrist• Commonly missed; long term complication is severe:

radiocarpal OA• MOI = FOOSH• Exam: tender over S-L area; positive scaphoid shift (Watson’s)

test (palpable clunk during palpation of scaphoid tubercle while patient goes from flexion/ulnar deviation to extension/radial deviation)

• Radiographs: standard AP may be normal; need “clenched fist”view; > 3mm S-L gap is positive (“Terry Thomas, Leon Spinks, David Letterman” sign); may have “ring sign”

• Refer to Ortho Hand surgeon; generally require reconstruction

Ring sign and scapholunate angle

Skier’s Thumb

• Sprain/tear of the UCL of the first

MCP joint

• AKA Gamekeeper’s thumb

• May have bony avulsion

• Get x-rays if possible before

testing

• Pain and swelling at site of UCL

• Stress testing of joint in 30° of

flexion

• May need MRI to look for Stener

lesion

Stener lesion

• Proximal end of the UCL

becomes trapped

superficial to the adductor

pollicis aponeurosis

• Requires surgical repair

Treatment

• If Stener lesion not present,

thumb spica splint for 4-6 weeks

• If Stener lesion is present, refer

to Hand Surgery

• Long term complication from

improper treatment is

osteoarthritis

Jersey finger

• Flexor digitorum

profundus tendon

rupture/avulsion

• FDP flexes the DIP joint

• MOI: forced extension

with active DIP flexion

(e.g., grabbing a jersey)

• Ring finger most

common

• Inability to flex DIP joint

• Tendon may retract into

palm

• All require urgent

surgical management

Central slip avulsion of the

extensor tendon� MOI: forced flexion of extended

PIP joint

� Swelling of PIP joint, tender on

dorsal side

� Unable to extend PIP joint

against resistance

� X-ray to assess for large avulsion

� Splint PIP joint in full extension

(leave DIP/MCP joints free) for 6-

8 weeks

Boutonniere deformity

• Late complication of central slip

injury

• Lateral bands drift volar to

rotation axis becoming PIP

flexors with DIP hyperextension

(proximal phalanx “buttonholes”

dorsally

• Deformity presents after several

weeks

• Usually requires surgery

Biceps Tendon Rupture• 90+% are proximal

• Distal ruptures require early diagnosis

• Majority require surgical repair due to significant loss of

supination strength

• Usually acute injury

• DDx: anterior capsule strain, coronoid process fracture,

lateral antebrachial cutaneous n. entrapment

• PE: biceps tendon not palpable in antecubital fossa

Distal Biceps Tendon Rupture

• X-rays to r/o avulsion fractures

• MRI to confirm complete tear

• Early surgical repair due to retraction/scarring

Pectoralis Major Injury

• Internal rotator and flexor of

humerus

• Two heads: sternal and clavicular

• Tear can occur at bony insertion

medially, M-T junction laterally

or in muscle belly (rare)

• MOI: usually acute pull/snap from

heavy lifting

• Rupture of inferior sternal head

easy to miss

• May see defect in “power prayer”

position

• MRI useful if diagnosis is unclear

• Surgical repair is dependent on

strength requirements for

sport/occupation

• Surgical outcomes better with

earlier repair, but late

reconstruction is possible

Complete Rotator Cuff Tear• Complete tears will often retract and scar down, making surgical

repair difficult if delayed

• More common in adults > 40 years old

• Often diagnosed as “tendonitis”

• Obvious weakness with RC testing (empty-can, drop-arm or lift-off

tests)

• Diagnostic injection can help to differentiate tear from

tendonitis/bursitis

• Untreated complete tears increase risk of GH osteoarthritis

Slipped capital femoral epiphysis (SCFE)

• Femoral head slips inferior and posterior to femoral neck

• Incidence 2/100,000 children; may be bilateral (20-40%)

• More common in boys (mean age 13 years) than females (mean age 11 years)

• Associated with period of rapid growth, obesity

• Highest risk group is African-American boys

• Present with painful limp; pain usually in groin but may be in anterior thigh or knee

(referred pain)

• Radiographic diagnosis

– Klein’s line, “ice cream off the cone”

• Surgery required

Legg-Calve-Perthes

• Avascular necrosis of femoral head leading to collapse and flattening of femoral head

• Etiology unknown

• Males >> females

• Most common in boys 4 – 10 years old

• Often painless, but will develop limp; easily diagnosed on x-ray

• Goal of treatment is containment of femoral head in acetabulum

– Bracing

– Physical therapy

• Blood supply generally returns over several months, leading to new bone growth

• In children under age 6 years old with appropriate treatment, greater chance of ending up with

normal hip joint

Femoral neck stress fracture• Often misdiagnosed or missed

• Extreme risk of displacement

• Result of overuse/repetitive stress

• Common in athletes, military recruits

• History of recent increased activity (frequency or intensity)

• Tension vs. Compression side

• Must get x-rays if suspicious; may take 2-4 weeks for x-rays to be positive

• Usually present with groin pain or anterior thigh pain with any weight-bearing

activity

• Further work-up required

if x-rays negative but

suspicious history

• Bone scan can be positive

within 24 hours of injury

• MRI extremely sensitive

• Treatment is dependent on

location, compression vs. tension

side

– Nondisplaced compression side

stress fractures treated

conservatively with NWB until

fracture is healed (6-8 weeks);

serial radiographs essential to

monitor for any worsening

– All tension side stress fractures are

treated surgically

Patellar/Quad Tendon Rupture

• Most common in 3rd & 4th decades of life

• Increased risk after ACL reconstruction using patellar tendon graft

• Risk factors: trauma, steroid use, quinolone use, DM, RA/SLE, chronic

tendonitis

• Inability to fully extend leg; focal deformity often present

• X-rays may show avulsion off patella or patellar migration

(inferior/superior); consider contralateral films for comparison

• Knee immobilizer (straight leg) and urgent Ortho referral

• Need to be repaired in first few weeks

Osteochondritis dissecans (OCD)

• Most common in the knee, but can also be seen in ankle,

elbow or any large joint

• Repetitive microtrauma/overuse leads to subchondral bone

death and subsequent articular cartilage fragmentation

• 20%-30% have bilateral involvement (knees)

• Radiographic diagnosis; MRI is the gold standard and used

for classification

OCD MRI Classification

• 4 stages based on MRI

• Stage I: low signal intensity

• Stage II: hypointense rim (no separation of lesion)

• Stage III: high signal intensity with underlying cystic

changes (instability)

• Stage IV: dislocation of fragment into the joint space

OCD Treatment

• Stage I: non-operatively with restricted weight-

bearing x 6-8 weeks

• Stage II: Non-operative if growth plates still open; in

adults it depends on the size of the lesion

• Stage III-IV: surgery

• Missed diagnosis can lead to permanent damage and

early degenerative joint disease

ACHILLES TENDON RUPTURE

• Classic patient: 30-40 y/o

male playing basketball (or

tennis)

• Classic history: “pushing off,

felt like I was shot in the back

of my lower leg”; loud snap

often heard across the court

• Rupture occurs in “watershed”

area 2-6 cm above insertion

Diagnosis

• Palpable defect

• Swelling/ecchymosis

possible

• Positive Thompson’s

test

• Imaging studies

obtained to r/o

avulsion fracture

Thompson Test

Treatment

• Casting vs. surgery

• Can treat non-operatively with serial casting

starting in equinus; long-leg cast required for the

first month

• Surgical repair allows for quicker weightbearing

• 6 months recovery time

LISFRANC INJURY

• Classic forced

plantar flexion injury

(trip down stairs)

• Midfoot injury

• Easily missed

• Beware of the

“burrito foot”

• WB films required

• Radiographic findings

can be very subtle

• Low threshold for MRI if

exam suspicious

• Refer to Ortho

foot/ankle specialist

• Midfoot DJD and chronic

foot pain if missed

JONES FRACTURE

• Proximal 5th MT diaphyseal fracture

• 0.5cm – 1.5cm from the proximal tip of the

5th MT

• Distinguish between tuberosity fractures

and Jones fracture

• “Jonesland” is area of very poor vascular

supply; high rate of non-union

Treatment

• Tuberosity avulsion fractures/stress fractures

treated in walking boot or hard-sole shoe

• True Jones fracture requires either prolonged

NWB cast immobilization (8-12 weeks) or

surgical ORIF

• Missed diagnosis leads to nonunion and chronic

foot pain

• Terminal end of the spinal cord is at L1-2

• Below this spinal canal is filled with the L2-S4 nerve roots, or cauda

equina (“horse tail”)

• Syndrome results from sudden reduction in volume of lumbar

spinal canal

– Central disc herniation

– Epidural abscess or hematoma

– Trauma/fracture with retropulsion

• Onset may be sudden or over hours

Cauda Equina Syndrome

• Symptoms

– Pain out of proportion; radicular pain/numbness bilaterally but worse on one

side

– Saddle anesthesia

– Lower extremity weakness/paralysis

– Urinary or bowel incontinence or urinary retention

• Surgical emergency

– STAT MRI

– STAT spine surgery evaluation

– Missed diagnosis can lead to permanent nerve damage and paralysis

Questions?