“Don’t-Miss”
Musculoskeletal Injuries
(Quiz time!)
MS3 Family Medicine
Goals
Review injuries you don’t want to miss
while an MS3
–
–
–
–
Shoulder
Back
Knee
Leg/Ankle/Foot
Review lessons learned in lectures
The 6-step msk exam steps are…
Inspection
Palpation
Range of motion
Strength
Neurovascular
Special Tests
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
Which aspect of examination is
particularly important early on?
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1. Inspection
2. Palpation
3. Range of
motion
4. Strength
5. Neurovascular
6. Special tests
Which xray view is needed to
determine direction of dislocations?
1. AP chest
2. Glenohumeral
AP
3. Scapular Y
4. Axillary
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Anterior or posterior?
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
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10
SITS in the rotator cuff muscles
stands for…
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
A 35 yo male falls off a 4-foot
ladder onto his elbow 1 week ago
and c/o shoulder pain
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
What’s your diagnosis?
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1. AC sprain
2. Humeral head
fracture
3. Impingement
syndrome
4. Rotator cuff tear
Treatment
Analgesics
Physical therapy referral
– Improve ROM, strength
Orthopedics consult if poor
improvement
– ? repair
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
Should you get an xray?
1. Yes
2. No
3. Don’t know
0%
Yes
No
Don’t know
What finding on xray would
prompt referral for surgery?
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1. Widened
mortise
2. Fibular avulsion
fracture
3. Soft tissue
swelling
High Ankle Sprain
AKA
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
In inversion ankle sprains, which
feature is not an indicator for an xray?
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1. Tenderness over
the ATFL
2. TTP over the
navicular bone
3. TTP over the 5th
MT base
4. Inability to bear
weight
Ottawa Ankle Rules
1.
2.
3.
4.
5.
When 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
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
Differential Diagnosis
ACL rupture
PCL rupture
Patellar
subluxation
Tibial plateau
fracture
Medial collateral
ligament strain
Meniscal tear
“Terrible Triad”
Which finding might prompt an
xray per Ottawa knee rules?
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1. Age of 20
2. Inability to
bend knee
>90d
3. Hx of trauma
4. Effusion
5 Ottawa Knee Rules
i.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
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.
What’s your diagnosis?
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1. Tibial plateau
fracture
2. ACL tear
3. Patellofemoral
syndrome
4. Meniscal tear
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
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
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”
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?
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Plica syndrome
ITB syndrome
MCL sprain
Patellofemoral
syndrome
Pl
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1.
2.
3.
4.
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
Back Pain
42 year old pilot
presents with LBP
Past medical
history significant
for chronic low
back pain
Denies any recent
trauma
He has these additional historical
features. Which of them is a “red
flag”?
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1. Pain radiating
below knee
2. Pain worse with
sitting
3. Numbness in
left foot
4. Recent fevers
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
At what neural level do you suspect
a deficit?
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L4
L5
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S1
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L5
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L4
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L3
1.
2.
3.
4.
5.
Differential Diagnosis
Herniated disk
Urinary tract
infection
Prostatitis
STD
Osteomyelitis
Epidural abscess
Tumor
Imaging
Plain films neg
Anything else?
MRI
– Epidural
abscess L4-5
Treatment
IV antibiotics
Orthopedic or
neurosurgical
consultation
Which is NOT a “red flag” in LBP?
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1. Age > 50
2. History of cancer
3. History of major
trauma
4. Recent fevers
5. Saddle anesthesia
6. Urinary retention
7. Sciatica
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
What type of xrays should you
order?
1. Tib-fib, ankle
and foot
2. AP/lateral foot
3. Weight-bearing
foot series
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What should concern you on xrays
of midfoot sprains?
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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
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
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Dr
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Dr. Phil
Aunt Lucy
Santa Claus
Dr. Kevin deWeber in
Rm A1033, or at
301-295-9466
Dr
.P
1.
2.
3.
4.
hi
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A medical student is thinking about
going into Family Medicine because
Sports Medicine is so awesome! Who
should he/she talk to?
25% 25% 25% 25%
QUESTIONS?