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Musculoskeletal Review
Cody Malley PA-C, LAT, ATC
NCAPA Winter Conference
February 2017
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Goals • To brush up on most common musculoskeletal
conditions
• Become familiar with most appropriate treatment
options
• Know what should be referred to an orthopaedic
specialist and what can be managed non
operatively without specialists help.
• Hopefully get every single ortho question right on
the PANRE!
• “Is this gonna be on the test?”….. I hope so
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SHOULDER
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Anatomy • Four joints: SC, AC, GH, Scapulothoracic
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Anatomy
• Rotator Cuff: Supraspinatus, Infraspinatus, Teres
Minor, and Subscapularis
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History • Age, hand dominance
• Work, sport
• Onset, injury
• progression
• Aggravating factors
• Night pain
• ROM
• Paresthesias, weakness
• Clunks, pops
• Instability
• Previous injuries,
surgeries, treatments
• Neck pathology
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Imaging
• Standard views: AP and axillary, Y view
oLooking for…
• Fracture
• Tumor
• Bony abnormalities (bone spurs)
• Position of humeral head
oElevated humeral head may be due to rotator cuff tear
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Standard Views
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Diagnostic testing • MRI 95% sensitivity and specificity in
detecting RCT o If looking for labral tear, need arthrogram
• CT arthrogram if implanted metal
• Ultrasound also useful for diagnosis
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Key Findings in H & P Symptoms Possible Diagnosis
Catching, popping Labral tear/instability (young), osteoarthrits (older)
Night pain, inability to lift arm Rotator cuff tear
Pain with overhead motion Impingement syndrome
Pain with developing stiffness over time
Adhesive capsulitis
Pain from shoulder down arm past elbow
Likely cervical spine pathology
Deformity, unable to use acutely Fracture/dislocation
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Impingement syndrome
• Pain with overhead motion due to subacromial bursa being inflamed
• Near normal strength when rotator cuff tested • Causes:
• Rotator cuff weakness • Partial rotator cuff tearing • Poor shoulder biomechanics Treatment • NSAIDs, rest, ice, activity modification, PT • Cortisone injection if other measures fail
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Impingement
Neer’s Done passively, not actively
Hawkins’ Done passively, not actively
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Rotator Cuff Disorders
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Rotator Cuff Tear
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Rotator Cuff Testing
Supraspinatus
Infraspinatus/Teres Minor
Subscapularis Subscapularis – Lift off test
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Imaging
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Rotator Cuff Tear vs. Tendinopathy • Tears usually > 40yrs
old unless traumatic
• Insidious onset, worse w/ overhead activity, night pain
• PE:ROM, Rotator cuff strength, Positive Hawkins/Neer’s
• Injections contraindicated if there is a full thickness tear or high grade partial thickness
• Imaging
• DDX: – Instability
– SLAP
– Bursitis
– Referred pain
– Calcific tendinitis
– Thoracic outlet syndrome
– Adhesive capsulitis
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Rotator cuff tear • Treatment
• Partial thickness tear
o Try PT, NSAIDs, ice, possible injection
• Full thickness tear
o Will not heal on it’s own
o Require surgical repair only in setting of minimal to no OA
• 4-6 month recovery
• If moderate to severe osteoarthritis with full thickness RCT, may need total shoulder arthroplasty
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Anterior Shoulder Dislocations
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Shoulder dislocation
• Anterior dislocation most
common
• Need reduction in timely
fashion to prevent
neurovascular
compromise
• Associated injuries o Bankart –anterior labrum
o Hill Sachs – impaction of posterior
humeral head
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Bankart Lesion
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Hill Sachs Lesion
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Posterior Shoulder Dislocations (GH Joint)
-Rare
-Epileptic Seizures
-Usually high velocity
-Often times has associated
trauma
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Shoulder dislocation treatment
• Anterior
o Young patients high rate of recurrence –
surgery likely
o Older patients (>40) w/ first time dislocation less
likely to recur – physical therapy
• Posterior
o No surgical intervention until seizures under
control
o If no seizures, may require surgery based on
severity of symptoms and activity
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Anterior Instability
Sulcus passive
Apprehension and
Relocation passive
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SLAP Lesions • Superior Labral Anterior Posterior
• Painful shoulder with clicks, pops with motion
• Positive clunk test, crank test, O’Brien’s, sometimes instability or biceps tendonitis
• MRI
• Conservative therapy- NSAID’s, PT, rest
• Arthroscopy vs open repair
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Labral Tears 1. Internal rotation,
cross body adduction, resist upward motion
2. Externally rotate arm in same position, resist same motion
PAIN w/ #1 and not #2 = POSITIVE O’BRIEN test
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SLAP lesion superior labrum anterior to posterior
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“SLAP” lesion
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AC Separation
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AC Separations
• 6 grades • Usually direct downward blow to shoulder,
fall on shoulder o Quarterback sack
• PE: “step” deformity, TTP AC joint, (+) crossover sign
• Radiographs: AP, Zanca (100 cephalic tilt), axillary
• Grade 3 and above should be referred for possible surgical fixation, otherwise conservative care (sling)
• RTP when pain-free with cross body adduction
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AC Separation Types
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AC Separation
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Anterior SC (sternoclavicular)
Dislocations
• Anterior usually MVA
• PE: TTP SC joint, deformity
• Radiographs: AP, 40 degree cephalic view
• Usually conservative management o Sling, ROM
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Posterior SC Dislocations
• Usually fall on flexed
and adducted
shoulder
• Can be life-
threatening
• Immediate referral and CT
• Closed reduction or
surgical reduction
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Biceps Tendinitis • Usually assoc. with other
pathology
• RCT, SLAP tear
• PE: TTP Bicipital groove,
Speed’s, Yergason’s
• NSAID’s, corticosteroid
injection, PT
• May rupture if RCT worsens
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Biceps Rupture – long head
• Usually > 50 yrs old
• Involves long head of biceps, short head rupture rare o John Elway
• “pop”, ecchymosis, deformity • “Popeye deformity”
• Conservative management
• MRI if diagnosis uncertain
• Tenodesis within 3-4 weeks of
injury if indicated o Reattachment of long head
biceps outside GH joint
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Adhesive Capsulitis • “Frozen Shoulder” • Contraction of capsule • Usually secondary to immobilization after injury
o Other illnesses- DM, thyroid, recent chemotherapy or radiation
o Female >> Male • Age 40-60 • Increased estrogen receptors around shoulders?
• Clinical diagnosis o ROM is key
• Lose external rotation first usually
• ? RCT • PT, NSAID’s, injections • May need surgical lysis of adhesions
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Three Stages of Adhesive Capsulitis • Painful stage (0-3 months) “Freezing”
• Pain with movement • Generalized ache that is difficult to pinpoint • Muscle spasm • Increasing pain at night and at rest
• Adhesive stage (3-6 months) “Frozen” • Less pain • Increasing stiffness and restriction of movement • Decreasing pain at night and at rest • Discomfort felt at extreme ranges of movement
• Recovery stage (>6 months) “Thawing” • Decreased pain • Marked restriction with slow, gradual increase in range of motion • Recovery is spontaneous but frequently incomplete
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Shoulder Fractures
• Proximal Humerus
o Surgical neck
common
o RX: Sling & ROM
o 3&4 part fx: ORIF
if: > 1cm
displaced or >
45° angulation
• Humeral Shaft o R/O Radial nerve injury
o 20° angulation acceptable
o Sarmiento brace
• Scapula o Non op treatment unless
extending to glenoid causing joint involvement
• Radiography: o Shoulder Trauma:
• AP Grashey
• Scapular Y view
o Humerus:
• AP and lateral
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Proximal Humerus fracture
• Surgical neck common site
• Most heal non operatively
o Sling for 6 weeks
• More than 2 part – ORIF
• Surgery if greater humeral head
45 degrees angulated
May result in hemiarthroplasty
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Humeral shaft fractures-Treatment
• Often non operative unless skin tenting
or unstable
oCheck Radial nerve function –wrist
drop
• Very proximal humerus fractures at
surgical neck require surgery –
hemiarthroplasty
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Clavicle Fractures • 5% of all fractures seen by FP
• Most are middle third, followed by distal third o Most common place at junction between middle
and distal 1/3
• Mechanism: FOOSH, onto shoulder, direct trauma
• PE: o edema and point tenderness over fracture site
o Assess ROM of neck, shoulder
o Motor strength, sensation
o Check for SC dislocations
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Treatment • Sling
o Comfortable, accessible
• Immobilize for 3-6 weeks in kids, 4-8 weeks in adults o Periodic ROM
o Discontinue when nontender at site, full ROM of arm without pain
o Surgery if skin or soft tissues being damaged by fracture, aesthetic reasons
• No contact sports for 6 weeks o Depends on site, sport, individual factors
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ELBOW
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Imaging • AP
o Even joint spacing
• Lateral
o Center of radius lines
up w/ center of
capitellum
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“Fat pad sign”
• Anterior fat pad –
normal
• Posterior fat pad –
always abnormal
• Suggests intraarticular
fracture o Children – supracondylar fx
o Adults – radial head fx
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Lateral Epicondylitis • “tennis elbow”
• Tenderness over the lateral epicondyle
• Pain with resisted wrist extension due to repetitive motions (tennis backhand)
• may have tear in tendon that requires repair
• Don’t confuse with radial tunnel syndrome (more distal)
• Tx: ice, NSAIDs, wrist immobilization, forearm strap, iontophoresis, cortisone injection
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Medial epicondylitis • Golfer’s elbow
• Mechanism:
Repeated flexion o Common flexor tendon
origin
• Dx: Resisted wrist
flexion/ pronation
• Rx: immobilize wrist to
rest wrist flexors, PT,
ice NSAIDs
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Elbow Instability
• UCL strain or tear – “little leaguer’s elbow”
• UCL primary valgus stabilizer
• Seen in the throwing athlete
• “Pop” heard while throwing with resulting medial elbow pain and hand paresthesia
• Pain on valgus testing
• X-ray, MRI
• Rx: Rest, NSAIDs, PT, slow return to sports
• Surgery: “Tommy John Surgery”
• Pitching education, especially in younger athlete
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Supracondylar
Fracture
• Most common elbow
fracture in children
• Extension mechanism,
distal fragment
posterior
• N/V injury common
• Casting vs. ORIF vs.
CRPP
• Types I, II, III
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Supracondylar Fracture – type II
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Supracondylar Fx – type III
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CRPP – closed reduction
percutaneous pinning
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Olecranon Bursitis
Non-infectious type
• Can occur when striking tip of elbow on hard object or from increased friction (leaning on hard desk)
• Pain free range of motion
• Treat with compressive wrap continuously
• Very susceptible to infection so have high threshold for aspiration
Infectious type (gout possible)
• red, tender, firm, patient febrile
• Painful range of motion
• May need surgical irrigation and debridement followed by IV antibiotics
• If mild and caught, po abx may be sufficient
• aspiration will rule infection in or out
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FOREARM, WRIST, AND
HAND
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Distal radius fractures • Colles fracture
o 90% of distal radius fractures
o FOOSH with wrist radially deviated
o Dorsal angulation
o All should be closed reduced and splinted even if surgery indicated
o May be treated non op if <10 degrees dorsal angulation
o Surgery: • CRPP in skeletally
immature
• ORIF vs external fixation for adults depending on severity of fracture, condition of skin, patient health
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Distal radius fractures • Smith fracture (reverse
Colles) o Fall on flexed wrist
o Volar angulation
o Unstable fracture
o Closed reduction difficult to
maintain
o Usually requires ORIF