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Diagnostic

Imaging
Lecture 3
Musculoskeletal
Musculoskeletal Injuries
Musculoskeletetal problems commonly
occur as a result of both serious athletic
pursuits and activities of daily living.
Most sports and recreational injuries are
the results of:
contusions,
sprains (ligamentous injuries),
strains (musculotendinous injuries),
meniscal injuries,
bursitis,
fractures, and
dislocations.
Physical therapy is an important adjunct
to the management of these disorders
Skeletal Imaging
Majority by plain radiograph
AP and Lateral projections
Oblique views for trauma involving joints, hands
and feet
CT - fine bone structure ( skull,spine and pelvis)
MRI - evaluation of soft tissue
Nuclear medicine - bone metastases,
differentiate cellulitis from osteomyelitis and
occult trauma (stress fractures)
Skeletal Imaging
Most bone lesions are obvious on clinical
history
>95 % bone films are obtained for:
Evaluation of trauma
Eval. Arthritis
Eval. Degenerative conditions
Metastases
Sprains
Sprains are ligament injuries.
Ligaments attach bone to bone
Ligaments are like strong cords, tough and
elastic, and provide stability and strength
between joints, but when pulled or stretched to
their limit they can tear or rupture.
Depending on the amount of ligament tearing,
a sprain can be mild, moderate, or severe.
An alternate classification is; a first-degree,
second-degree or third-degree sprain.
Sprains

1rst degree - joint pain / tenderness


- no laxity

2nd degree - joint laxity present


- pain and tenderness

3rd degree - ligament broken


- unstable joint
Sprains
Most sprains are associated with varying degrees of
pain, swelling and impairment of range-of-motion or
weight bearing.

The most commonly involved areas are the shoulder, the


elbow, the knee and the ankle.

Knee and ankle sprains are among the most common of


all sports injuries.
If the physical exam is difficult to perform or damage to
other intra-articular structures is suspected, an MRI can
help determine the full extent of injury.
Strains
A strain is the tearing of a muscle-tendon unit.
termed tendonitis
acute or chronic
caused by overuse or a single episode of
overactivity
pain results from minor tears in the tendons ,
from accumulated injuries (repetitive micro-
trauma) that outpace the bodys ability to repair
itself.
Strains
may result in pathologic changes of the
soft-tissue and bones:
tendon degeneration, osteophytes, stress
fractures, or nerve entrapment.
also graded as mild, moderate or
severe.
Severe strains are characterized by
rupture of any part of the tendon
complex e.g biceps, patella or Achilles.
Terminology
Fracture is a break or loss of structural
continuity in a bone.
it is important that fractures be described in a
precise and detailed manner.
Dislocation and Subluxation alters the normal
relationship between joint surfaces.
Dislocation :the normally apposing joint
surfaces completely loose contact
Subluxation :those surfaces are only
partially separated.
Fractures are described
Description
Fracture
displacement
Fracture
Angulation
dorsal volar
Fracture
Rotation
Fracture
Bayoneting
Fracture
Distraction
Fracture
Oblique
Fracture
Greenstick
Fracture
Transverse
Fracture
Comminuted
Fracture
Spiral
Fracture
Dislocation
Fracture
Nonunion Malunion
Fracture
Avulsion
Fractures
Fractures are open or closed.
Open: break in the surrounding skin or mucosa
that allows the fracture to communicate with the
external environment.
Open fractures are graded 1-3, with 3 being the
most severe, and having the highest incidence
of complications (e.g. osteomyelitis and
nonunion).
Open fractures
Grade 1: wounds < 1cm in length
Grade 2: wounds > 1cm in length
but clean w/o devitalization of tissue
Grade 3: wounds > 1 cm in length,
grossly contaminated,
associated with comminuted
fractures and vascular
injury.
Open fractures - surgical emergencies
debrided, irrigated
(parenteral antibiotics within 6 hours)
Fracture Description
Fractures are further described based on:
Location
Pattern
Displacement

When describing location,


the bone affected is identified
as well as the specific part of the bone involved (proximal or
distal epiphysis,etc.)
Fracture location has implication for healing.
Fractures of metaphyseal or cancellous bone usually heal
quite rapidly in contrast to cortical or diaphyseal bone, which
heals more slowly due to differences in blood supply and
bone turnover rate.
(Physis)
Fracture Pattern
The fracture pattern relates to fracture
geometry, which suggests the type and
amount of kinetic energy the bone has
been subjected too.
A transverse fracture is a low-energy injury,
usually the result of either a direct blow to a
long bone or a ligament avulsion.
An example is a night stick fracture, which
involves the ulna and occurs when the forearm is
used to defend against an assault.
Stress and pathologic fractures usually
have a transverse pattern.
Fracture Pattern
Spiral or oblique fractures result from a rotatory
or twisting injury.
These fractures have a tendency to displace after
reduction and immobilization.
Spiral or oblique fractures typically require ORIF.
A fracture with two or more fragments is termed
comminuted.
Subtypes are called butterfly fragments and
segmental fractures.
Fracture Pattern
An impacted fracture is commonly seen in
metaphyseal bone, such as the femoral neck,
the distal radius or tibial plateau fractures.
These (impacted) are low-energy injuries in which
two bone fragments are jammed together .

Fractured bone fragments can be displaced


due to the force of the injury, gravity, or muscle
pull.
Displacement is described in terms of
angulation, rotation and length .
Salter-Harris (Growth Plate)
Fractures
Growth plate fractures in children are based on
the Salter-Harris classification of injuries.

Growth plate injuries, no matter how trivial,


have the potential to cause growth disturbance
of the involved bone.

These fractures are classified as type I-V.


Salter-Harris Classification
Type I- through the physis.

Type II- through the physis and


metaphysis.

Type III- through the physis and


epiphysis.

Type IV- through the physis,


metaphysis and epiphysis.

Type V- crush injury to the


physis.
Principles of fracture management:
Patients with fractures should be managed as trauma
patients.
always check for associated injuries (ABCs).
Next, assess the neuro-vascular status.
Remember to check :
distal pulses and capillary refill.
sensory and motor function
(distal to the fracture )
Fracture management
The three principles of fracture care
involve:
1) Reduction of deformity

2) Maintenance of reduction

3) Rehabilitation of function
Closed reduction
Reduction
Closed
Open
Closed reduction: involves the manual
manipulation of the fracture into a functional
position.
traction is applied
deforming forces are reversed
realign the bone fragments.
Open reduction
open reduction
fracture is surgically exposed
bone fragments are manipulated directly
(ORIF=open reduction and internal fixation).

Open reduction indicated when:


closed reduction methods fail
with intra/articular fractures (joint surface must be
aligned anatomically to prevent the development of
posttraumatic arthritis.
Maintaining alignment
Maintaining alignment requires
Immobilization:
include casting, splinting, traction, functional bracing, and
internal or external fixation.
The type of immobilization depends upon fracture
stability or its propensity for displacement.
Splints and casts immobilize and support the injured
extremity and thereby reduce pain
prevent injury to structures in the proximity of a
fracture, and maintain alignment after reduction.
Splinting and casting are also used postoperatively to
provide additional stabilization when fixation is
tenuous.
Splinting and casting
Splinting and casting accomplished with plaster
or synthetic materials such as fiberglass.
Splints differ from casts in that splints are not
circumferential and thus allow swelling of the
extremity without a significant increase in
pressure within the splint.
Swelling within the cast increases pressure,
potentially resulting in a compartment
syndrome or pressure sores.
Splinting and casting
Many of the fundamental rules of splinting and
casting are identical.
Ideally, at least one joint proximal and one joint
distal to the injury are immobilized.
Prior to immobilization, fractures are reduced,
and, as much as possible are placed in a
position of function.
The extremity and bony prominences are
padded to prevent pressure sores and
neurovascular compression.
Complications
Common complications of musculoskeletal
injuries:
ARDS (fat embolism)
DVT
Atelectasis
Nerve compression
Osteomyelitis
Shoulder
Normal
Acromioclavicular (AC) separation
(separated shoulder)
Mechanism of injury- fall onto point of shoulder
If there has been significant disruption (or a fracture to
the clavicle itself), the area will appear swollen and
deformed compared with the other side.
The patient will avoid movement, due to pain.
Gently have the patient move their arm across their
chest while you palpate in the AC region.
This will cause pain specifically at the AC joint if
there is separation.
Tenderness is felt at the junction, or the site of the AC
(acromioclavicular) joint.
AC separation (cont)
Grade I:
AC ligament sprained, but joint remains intact
Grade II:
Rupture of AC ligament and joint separation
Grade III:
Coracoclavicular and AC ligaments ruptured with wide
separation of joint
Tx:
Grade I-II: sling, ice x 2 wks then ROM
Grade III: sling, ice x several wks until pain subsides, then
ROM & strengthening vs. surgical repair
Anterior Glenohumeral Dislocation
Shoulder dislocation
Mechanism of injury:
From external rotation & abduction force on humerus
From a direct posterior blow to proximal humerus
From a posterolateral blow on the shoulder
Exam:
Space underneath acromion where humeral head should lie
Palpable anterior mass representing humeral head in
anterior axilla
Tx:
Closed reduction
Immobilization in internal rotation
Shoulder dislocation
------Normal

Shoulder dislocation->
Anterior
dislocation

(Much
more
common
than
posterior
dislocation)
Posterior
dislocation
Anterior Glenohumeral Dislocation
Complications
2 lesions with recurrent dislocations:

Bankhart Lesion:
Anterior capsular injury assoc with a tear of the glenoid
labrum off the anterior glenoid rim

Hill-Sachs Deformity:
Compression fracture of the articular surface of the
humeral head posterolaterally that is created by the sharp
edge of the anterior glenoid as the humeral head
dislocates over it
Hill-Sachs
Deformity
Clavicle fracture
Most common bone fractured
Weakest aspect is junction of middle/distal thirds
Look for Tenting of the skin
Class A (middle third fractures) (80%):
Treat with sling immobilization.
Some prefer using a figure-eight clavicular splint, especially for displaced
fractures.
Class B (distal third fractures) (15%):
Treat type I (nondisplaced) and type III (articular surface) fractures with
sling immobilization.
Immobilize type II (displaced) fractures in a sling and swathe.
These may require orthopedic surgical fixation.
Class C (proximal third) (5%):
Treat nondisplaced fractures with sling immobilization.
Displaced injuries may require orthopedic referral for surgical reduction.
Neonatal fractures generally heal spontaneously in several weeks without
special treatment.
Normal---

-----Normal

Fracture----
Shoulder Fractures
Proximal Humerus Fractures:
Neer classificaton:
Non-displaced fractures:
are displaced less than 1cm or angulated <45
degrees, regardless of the fracture pattern or # of
fragments
Displaced fractures:
2 part fxs are fractured either through the anatomical
neck, surgical neck, greater tuberosity or lesser
tuberosity
3 part fxs are fxs of the surgical neck with fractures of
either the greater tuberosity or lesser tuberosity
4 part fxs are fxs of the anatomic neck & fractures of
the greater and lesser tuberosities
Proximal Humerus Fracture
The vascularity is at risk with anatomical neck
fractures
Most common mechanism of injury= FOOSH
Signs & symptoms:
Pain, swelling, tenderness
Tx:
For nondisplaced fxs= sling, begin ROM exercises
2 part/3 part fxs= closed reduction, sling, possible
ORIF
Absolute indication for hemi-arthroplasty: 4 part fxs,
non-reducible 3 part fxs
Midshaft Humerus Fractures
Signs & Symptoms:
Arm pain, swelling, deformity
The arm is shortened with gross motion & crepitus on gentle
manipulation
XR:
AP/lat c shoulder & elbow
Tx:
Coaptation splint
Carefully molded plaster slab placed around medial & lateral aspects
of arm, extending from axilla around elbow & over deltoid & acromion
x 2 wks
Change to Sarmiento brace @ 2 wks
May require ORIF with plate/screw or intramedullary nailing
Midshaft humerus fx
Elbow Fractures
Monteggia Fracture
Usually a fx of the proximal Ulna with anterior
dislocation of the radial head
MOI:
Forceful pronation or direct blow to dorsum of ulna
H&P:
Pain & h/o trauma, may have obvious deformity
XR:
AP/lat/obliq
TX:
Hematoma block, reduction, long arm cast or splint
May require ORIF
Galeazzi Fracture/dislocation
involving distal radial shaft fracture with associated
dislocation of the distal radioulnar joint (DRUJ), which
disrupts the forearm axis joint.

"fracture of necessity" refers to the adult Galeazzi


fracture not being amenable to treatment by closed
means, necessitating surgical stabilization.
Galeazzi
(Reverse Monteggia)
Galeazzi
Radial Head Fracture
MOI:
Fall forward with elbow extended, forearm pronated
Pain localized to radial head
XR:
AP/lat/obliq
If fracture is subtle, look for fat pad, or sail signs
TX:
Types I, II, & III without mechanical block are treated with a
sling and AROM x 3 wks
After 3 wks d/c sling & begin aggressive PT
Fxs with elbow instability or mechanical block are treated
operatively with either reduction & fixation of head, excision
of head, or ligament repair
Normal Elbow
Radial head fx
Olecranon Fractures
Pain @ elbow with h/o trauma
XR:
AP/lat/obliq
Management
Initial: sling for comfort
Definitive:
non-displaced fxs can be managed with posterior
splint @ 90 degrees flexion x 2 wks
Other fxs are managed with ORIF or percutaneous
pinning & early motion post-operatively
Olecranon Fractures
Olecranon Fractures
Distal Humerus Fracture
Supracondylar fxs of the Humerus:
Characterized by dissociation b/t diaphysis & condyles of
distal humerus, frequently extended distally & involves
articular surface
Caused by FOOSH or direct blow
PE:
+ deformity, instability, crepitus
XR:
AP/lat/obliq
Management:
Initial: alignment, immobilization, ice, long arm splint
Definitive: ORIF, early motion
(Other fxs: transcondylar, medial condyle, lateral
condyle)
The Wrist-Eight Carpal Bones
Some Lovers Try Positions That They
Cannot Handle
Proximal / Distal row from radial to ulnar position
Scaphoid,Lunate,Triquetrum,Pisiform,
Trapezium,Trapezoid,Capitate,Hamate

+ Radius and Ulna


Movements at the wrist
Radial deviation (abduction)
Ulnar deviation (adduction)
Flexion
Extension
Supination
Pronation
Combination of all of the above
Wrist Dislocations
Perilunate, and Lunate dislocations are
variations of the same injury
Caused by hyperextension of the wrist (FOOSH)
Exam:
Note areas of ecchymosis, active ROM,
neurovascular status
When dislocated, wrist appears shortened with a
fullness over the dorsum or in the carpal tunnel
Any movement produces pain
Swelling varies from barely perceptible to significant
Wrist Dislocations
XR:
Minimum 4 views: AP neutral, AP ulnar deviation,
oblique, lateral
Tx:
Reduce ASAP to minimize risk of median nerve
injury
Axillary block or IV regional block provide adequate
muscular relaxation.
Apply traction for 5-10 min using finger traps
Reduce & place in thumb spica plaster splint with
wrist in neutral or slight palmar flexion
Post reduction films are required
May Require surgery for adequate reduction
Perilunate dislocation Perilunate dislocation
Lunate dislocation
Distal Forearm Fractures
1. Extension fractures:
Colles Fracture
Fx distal radius with dorsal
angulation of distal fragment and
associated fx of the ulnar styloid
Usually 2* to FOOSH
Exam:
swelling wrist, decreased ROM
secondary to pain
XR:
AP/true lateral/obliq- radius will be
shortened
Colles fx
Colles fx
Distal Forearm Fractures (cont)
Colles Fx (cont)
Tx:
Hang in finger traps
Hematoma block:
Using an 18 gauge needle & 20cc syringe with 10cc 1%
lidocaine, enter fx site & aspirate hematoma (blood will flow into
syringe)
After aspirating hematoma, inject lidocaine into fx site
Wait several minutes until pain is decreased & reduce fx
Place in long arm cast (LAC) with wrist @ 20-30 degrees
of flexion & ulnar deviation
Post reduction films are necessary
Ice, elevate above level of heart, NSAIDs,
analgesia
Distal Forearm Fractures (cont)
2. Non-displaced Distal Radius Fxs
Require short arm cast (SAC) in neutral, ice, elevation,
NSAIDS, analgesia
3. Other common fxs:
Smiths fx
Reverse Colles fx
Fracture of the distal radius with palmar (volar) displacement of the
distal fragment.
Die Punch Fx
Intra-articular distal radius fx with impaction of the dorsal aspect of
the lunate fossa
Bartons Fx
Displaced intra-articular lip fx of the distal radius
May be assoc with carpal subluxation
May be dorsal or volar configuration
Extends into radio-carpal joint
Smiths fx
Smiths Fx
Scaphoid Fractures
MC fxd carpal bone
There is no direct blood supply to the proximal
portion of the scaphoid
Therefore, scaphoid fxs have a tendency to
develop delayed union or avascular necrosis
Remember the more proximal the fx line is in
the scaphoid injuries, the greater the likelyhood
of avascular necrosis
Mechanism of injury
Forceful hyperextension of the wrist
Scaphoid Fractures
Exam:
+ snuffbox tenderness,
radial deviation of wrist will probably elicit pain
XR:
Obtain AP/lat/obliq/scaphoid views
Initial plain xray may not demonstrate fx for up to 4 wks
If xrays are still negative at 10-14 days & pt is symptomatic,
obtain bone scan for definitive diagnosis
A bone scan will show an increase in uptake in fracture area
Tx:
Initially in ER:
Thumb spica (*always tx snuffbox tenderness, even if xr neg)
Definitive:
Long arm thumb spica cast x 4-8 wks.
If scaphoid is displaced, may require ORIF
A. Thumb
B. Index
C. Middle finger
D. Ring finger
E. Little fingerI-V. Metacarpal
bones1,4. Distal phalanx
2. Middle phalanx
3,5. Proximal phalanx
6. Sesamoid bones
7. Distal interphalangeal joint
(DIP)
8. Proximal interphalangeal
joint (PIP)
9. Metacarpophalangeal joint
(V.)
10. Carpometacarpal joints
11. Trapezium
12. Trapezoid
13. Capitate
14. Hamate
15. Scaphoid
16. Lunate
17. Triquetrum
18. Pisiform
19. Radius
20. Ulna
Game Keepers Thumb
Skiers Thumb
Injury to the ulnar collateral ligament of the MCP joint
of the thumb
Destroys joint stability
Impairs ability to pinch
Evaluation:
Stress ulnar aspect of the MCP joint by forcing thumb
into radial abduction
If there is <15 degrees of side to side difference (one thumb
compared to the other) or an opening > 45 degrees at the
ulnar aspect of the MCP joint, surgical repair is required
Closed tx with a thumb spica cast or splint with the thumb
slightly adducted may allow for healing of an incomplete tear
Distal Phalangeal Fractures
1. Closed:
Splint, Ice, Analgesia
2. Open:
Digital block c 1% lido local anesth.
Irrigate
? Rongeur
Sterile repair (suturing) of nailbed, place nail as
biological dressing
Xeroform gauze (betadine/petroleum imbedded
gauze) & sterile gauze dressing
Splint
Antibiotics
Middle & Proximal Phalanx
Fractures
Stable, non-displaced, impacted, transverse
fxs with no rotational deformity of the finger
may be either buddy taped or splinted with mcp
joints flexed @ 50 degrees & PIP joints flexed
@ 15-20 degrees
Fxs with rotational deformities may require
closed or ORIF & casting/splinting
Unstable fxs may require casting or
percutaneous pinning with Kirschner (K) wires
More recently these fxs are being internally fixed
with plates & screws from small fragment sets
Finger dislocation

Reduce
Splint
Metacarpal Neck Fractures
Most frequently occur at the 5th metacarpal
(Boxers fx) as a result of a direct blow
delivered to the hand or by the hand to a solid
(animate or inanimate) object while the hand is
held in a fist
Other Metacarpal Fxs
Bennetts
Rolandos
Lower Extremities

Second
Part
Knee
Standard Xray projections:
AP eval.joint space narrowing / calcifications
Lateral eval.Patella / effusions
Special views
Sunrise / merchant view
Tangential / knee flexed/from top-down
Tunnel view
Knee more flexed, looking through the tunnel
created by the femoral condyles
Knee
Most common reasons to order Knee
X rays are:
- trauma
- DJD ( X rays findings)
MRI soft tissues
- tendons, ligaments, menisci, and
cartilage
Knee
The Knee
Ligaments:
Anterior Cruciate Ligament (ACL)
Posterior Cruciate Ligament (PCL)
Medial Collateral Ligament (MCL)
Lateral Collateral Ligament (LCL)
Knee
Knee effusion:
Best seen on Lateral view
Superior to Patella
Anterior to distal femur
Water or blood
Same density as muscle
Look for anterior displacement of fat line
Clinical examination superior to X ray
Knee soft tissue injuries
Most common:
Cruciate ligaments: Xrays NL. Dx made on
clinicals
and the menisci : plain film shows degree of
joint space narrowing and possible loose body
within the joint
MRI only if PE inconclusive
ACL- originates in front of the intercondylar
eminence of the tibia and inserts on the
posteromedial aspect of the lateral femoral
condyle.
Lateral medial
The ACL prevents anterior
translation of the tibia
PCL-Originates on the medial femoral condyle
and inserts on the tibia.
Medial lateral
The PCL prevents
posterior translation
of the tibia
Medial Collateral Ligament
(MCL)
Originates on the medial femoral
epicondyle and inserts on the proximal
tibia
The MCL
prevents
valgus angulation
of the knee
Lateral Collateral Ligament
(LCL)
Originates on the lateral femoral
epicondyle and inserts on the lateral
aspect of the fibular head.
It prevents varus
angulation of the knee
Menisci
Crescent shaped fibrocartilagenous structures that are
triangular in cross section.
Only the peripheral 20-30% of the menisci are
vascularized
These structures deepen the articular surface of the
tibial plateau adding stability to the joint
Meniscal Tear
Most Common injury to the knee requiring
surgery
Medial meniscal tears occur 3x more frequently
than lateral meniscal tears
From acute trauma or chronic long term wear
and tear
Locked knee requires urgent intervention
Meniscal Tear Diagnosis
History:
Locking, clicking sound
catching episodes / giving way episodes
pain with squatting / Swelling
Physical Exam:
+ effusion
+ joint line tenderness
+ McMurrays sign
Meniscal Tear
Treatment:
Meniscal repair may be achieved arthroscopically
by suturing the torn meniscus
This may be an option if tear occurs in an area with blood
supply
Partial meniscectomy
Arthroscopic removal of the torn meniscus
Ligament Sprains
Ligament sprains
Medial Collateral Ligament
(MCL)
Sprain
Caused by valgus force to knee
Diagnosis:
+ tenderness along MCL (Grade I-III)
+ opening of medial joint line with valgus stress when knee
is @ 30 degrees of flexion (Grades II-III)
(Posterior Cruciate Ligament is most responsible for medial-
lateral stability when knee is fully extended)
Tx:
Ice
NSAIDS
Physical Therapy
Grade III sprains may require surgical repair
Lateral Collateral Ligament (LCL)
Sprain
Caused by varus force to knee
Uncommon
Dx:
+ tenderness along LCL (Grade I-III)
+ opening of lateral joint line with varus stress
when knee is @ 30 degrees of flexion
Tx:
Non-operative:
Ice
NSAIDS
Physical therapy
Anterior Cruciate Ligament (ACL)
Sprains
Caused by twisting of knee while
foot is firmly planted on ground
Hx:
Patient hears a pop feels a tear and
acute pain in knee
Knee may feel unstable with weight
bearing
Acute swelling at time of injury
Anterior Cruciate Ligament (ACL)
Sprains
Dx:
+ Lachman (20-30 degrees flexion, pull tibia anteriorly)
+ anterior drawer (90 degrees)
+ pivot shift with anterolateral instability
Arthrocentesis reveals hemarthrosis
MRI >90% accurate
Tx:
Physical therapy (pre/post op)
Open vs. Arthroscopic surgical reconstruction with patella
tendon or hamstring tendon autograft; allograft (cadaver);
xenograft (another animal)
CPM (continuous passive motion machine) and hinged
knee brace post-op
If stable = no surgery nec.
ACL tear
Posterior Cruciate Ligament
(PCL) Sprain
Caused by hyperextension of knee or direct
blow to anterior aspect of flexed knee
(Dashboard)
Dx:
+ posterior drawer
MRI >90% accurate
Tx:
Physical therapy
Surgical reconstruction in patients who have
high demand knees (athletes) and severe
instability
Unhappy Triad

This is the term given to an injury where the


ACL, MCL and Medial Meniscus are all
three torn.
The mechanism for this injury is usually a
lateral blow to the knee with the foot fixed.

1. ACL tear
2. MCL tear
3. Medial meniscus tear
Patellar Tendon Rupture
Most frequently in patient <40 y/o
Exam:
Patient cannot actively extend knee
Palpable defect inferior to patella
Xray:
+ patella alta
Tx:
Surgical repair
Weight bear as tolerated (wbat) with knee in extension
Patella tendon
rupture
Notice superior
appearing patella

Normal Knee
Patella Dislocation/ Subluxation

Lateral displacement of patella


Acute vs. recurrent
Reduction occurs with knee in extension
+ patella apprehension test
Tx:
mobilization and strengthening exercises
Vs.
Immobilization in cylinder cast x 6 wks
Vs.
Surgical repair
Patellar fractures
Direct blow to patella fall
Dark lines across the bone
Sharp corners and edges
Repair by fixation pins and wire
Patellar fracture
Chronic Knee Pain
DJD OA vs RA -
PE
Decreased ROM
No systemic symptoms
Plain radiographs for initial workup (standing)
X ray findings
joint space narrowing (Medial common)
Spurs
Sclerotic bony margins
Loose body: disruption of cartilage , single
broken piece.
If multiple pieces synovial
chondromatosis
Chondrocalcinosis : calcification within
articular cartilage of the joint (DJD,
hypercalcemia, pseudogout) linear
calcifications
Knee Replacement
Indicated for severe DJD
Femoral condylar component
Proximal tibial component
Patellar component
AP- may look like components are not
touching plastic component not seen on
Xray
Infection and loosening
Both look as lucent space around screws
and base of the implant
Foot
Bones of the foot:
7 tarsals
Talus
Calcaneus
Navicular
Medial Cuneiform
Intermediate Cuneiform
Lateral Cuneiform
Cuboid
5 metatarsals
rays of the foot
14 phalanges
Plantar Fasciitis
Plantar fasciitis is the #1 most common foot
problem.
It is caused by activity, overuse and aging.
Plantar fasciitis is an inflammation due to
repeated overstretching of the plantar fascia
ligament (fat pad of the foot), usually at the
point where the fascia is attached to the
calcaneus.
Pain is most severe in the morning and
stepping down onto foot, decreases as day
goes on
Plantar Fasciitis
Contributing factors are:
flat (pronated) feet
high arches (supinated feet)
increasing age
sudden weight increase
sudden increase in activity level
running in sand
hereditary factors
Xray: May reveal bony spur at same site
Plantar Fasciitis
Tx:
Achilles stretching (tennis ball)
massage
Rest from activities
NSAIDS
Shock absorbing heel cups
Ankle orthosis (AFO) for recalcitrant cases
Avoid cortisone injections
Hallux Valgus
Most common deformity of the foot
Results in excessive valgus angulation of the big toe
Splaying of the forefoot with varus angulation of the first
metatarsal predisposes
The anatomical deformity consists of:
Increased forefoot width
Lateral deviation of the hallux
Prominence of the first metatarsal head
Clinical features
More common in women
Often bilateral
Symptoms result from
A bursa over metatarsal head = bunion
Osteoarthritis of the first MTPJ
Hallux Valgus
Xray:
Bilateral weight bearing AP/ lateral/ oblique foot
Initial Tx:
Shoewear education/ modification (sneakers)
Surgical Tx:
Distal metatarsal osteotomy +/- internal fixation for
mild deformity
1st tarsal metatarsal arthrodesis (fusion) for
hypermobile 1st ray
Lisfranc Injury
Fracture and lateral dislocation of 2nd, 3rd,4th and 5th
metatarsals relative to the tarsal bones
MOI: falling out of a saddle, foot caught on stirrup, or
stepping into a hole with twisting of the foot
Exam:
+ tenderness at Lisfranc joint
+ swelling dorsally
XR:
AP/ lateral/ oblique foot (weight bearing when possible):
May reveal widening at joint
Tx:
Reduced & treated with screw fixation
NWB x 6-8 wks
Jones Fracture/Dancers fracture
Transverse fracture of the 5th metatarsal at the
junction of the proximal metaphysis & diaphysis
PE:
+ tenderness lateral aspect of foot
+ swelling
+/- ecchymosis
XR:
AP/ lat/ obliq
Tx:
Short leg cast (SLC)
Non-wt bearing (NWB) x 6wks
Frequently fail to heal when treated non-operatively,
especially in smokers
Surg:
ORIF
Jones fx
Avulsion Fracture of the base of the
5th Metatarsal
Pseudo-Jones fx/ dancer fx/ tennis fx
Occurs when the insertion of the peroneus brevis is
avulsed during forced inversion of the forefoot
Exam:
+ tenderness
+ swelling at base of 5th metatarsal
+/- ecchymosis
XR:
AP/lat/obliq
Tx:
Short leg walking cast (SLWC) x 6 wks
Pseudo-Jones Fracture
Dancer Fracture
Tennis Fracture
Avulsion Fracture
Pseudo-Jones Fracture
Comminuted Fracture of
proximal and/ or distal phalanx
of great toe
XR:
AP/lat/obliq
Tx:
Splint
Hard sole shoe
Ice
Buddy tape
Fractures of phalanges of lesser
toes
XR:
AP/lat/obliq
Tx:
Buddy tape
Ice
NSAIDS
March Fracture
Stress fracture usually of the middle of the shaft
of the 3rd metatarsal (or 4th)
History of having gone on long walk/march with
no clear h/o trauma
Also seen in females with eating/exercising
disorders
Exam:
+ tenderness midshaft of the involved metatarsal
Pain with increased flexion or extension of toes
Pain subsides with rest
March Fracture
Initial XR:
AP/lat/obliq weight bearing foot will be negative
Follow up XR:
In 2 wks will show callus formation
Tx:
Symptomatically with crutches or if patients
occupation requires prolonged standing or
ambulation
SLWC x 3-4 wks
Stress fx
Calcaneus Fractures
May be intraarticular or extraarticular
h/o fall or twisting injury & pain localized to hindfoot
(tarsal)
XR:
AP/lat/obliq/ axial heel/ Brodens view (lateral xray with foot
passively dorsiflexed/ supinated & internally rotated)
Should have CT scan to review extent of fx
Also do Xray of Lumbar spine due to associated fxs
Initial management:
Splint
Ice
Elevation
Calcaneus Fracture
Tx:
Non-displaced intraarticular fx= NWB 4-6 wks
Displaced intraarticular fx= ORIF, NWB x 6-8 wks,
early motion
Minimally displaced tuberosity fracture= NWB 3-6
wks
Displaced tuberosity fx= internal fixation, NWB 4-
6wks
Sustentaculum tali= SLWC x 4-6 wks
Non-displaced anterior process fx= SLWC x 4-6 wks
Displaced anterior process fx = ORIF
The Ankle
Bones
Tibia
Fibula
Talus

Obtain AP/lat/obliq
to r/o fracture
Anterior fat line
displacement with
effusion (Lateral
view)
Ankle sprains
Inversion injury= MC mechanism of injury / injures
lateral structures of ankle
MC ligament sprained=
1. Anterior talofibular ligament (front) - tears first
2. Posterior talofibular ligament (back) - tears second
3. Calcaneofibular ligament (middle) - tears last
Tx:
Ice x 20min several x/day
Elevation
NSAIDS
WBAT c crutches prn
Early ROM
strengthening
Ankle fractures
Most common:
Medial or Lateral malleolus
Severe trauma trimalleolar fracture
When severe associated ligament damage
and subluxation of distal tibia over the talus
Stress views when NL Xray (standard) and
high clinical suspicion of trauma
Bi - Malleolar fracture
Ankle inversion injury:
Horizontal fibular fracture and oblique medial
malleolus fracture

Ankle eversion fracture:


Horizontal medial malleolus fracture with oblique
fibular fracture
Bimalleolar fracture-inversion injury
Foot Fractures
Can involve any bone
Talus fractures are rare - MVAccident
Calcaneous fracture hard to see in
standard views order calcaneal view
Place foot on film and shooting down
along the back side of the ankle
Achilles Tendinitis
Pain at achilles tendon, increased by running
decreased by rest
Pain is often worse following activity, rather
than during
Often palpable thickening over tendon or
peritendinous tissues
Achilles Tendon Rupture
Occurs most commonly at narrowest portion of
tendon approx. 2 inches superior to point of
attachment to calcaneus
Mechanisms of injury:
1. extra stretch applied to taut tendon
2. forceful dorsiflexion with ankle in relaxed
state
3. direct trauma to taut tendon
Achilles Tendon Rupture
C/O acute pain in lower calf & difficulty
ambulating
+/- palpable defect or mass in post. calf
+ Thompson test
squeeze calf, foot should plantarflex, if no
plantarflexion then achilles tendon is out
Tx:
1. surgical repair
2. equinus walking boot x 8 wks followed by 2.5 cm
heel for another 4 weeks
Tibial Shaft Fractures

Mechanisms of injury
1. direct trauma: MVA, skiing, (boot top)
2. indirect trauma: assoc with rotary & compressive forces
as from skiing or a fall

Exam:
Pain, swelling, deformity
XR:
AP/lateral tibia fibula
Tibial Plateau Fractures
Involve proximal articular surface of tibia
Exam:
Pain localized to proximal tibia, +/- swelling
Imaging:
AP, lateral knee
CT scan
Tibial Plateau Fracture Classification
Hip
Xray views
AP and frog legs (abducted)
Lateral views hard to interprete
Evaluate the relationship of femoral head
to the acetabulum
Look for cortical discontinuities
Look at trabecular pattern
Hip dislocations
From M V Accidents
Most common posterior dislocation
On AP - head of femur located superiorly and laterally
displaced
Anterior dislocation: inferior and medial
Look for associated fracture fragments from the
acetabulum
Hip dislocation
Posterior dislocation:
Head of the femur
superior and laterally
located

Anterior dislocation:
Head of femur located
inferiorly and medially to
the acetabulum
Hip fractures
90% of hip fracture either at:
Femoral neck - Osteoporotic
Unable to walk after a fall
Little deformity
Intertrochanteric - post traumatic
Shorter leg in internal rotation
Stress frx dificult to detect in elderly
Nondisplaced frx better seen
MRI
Bone scan ( may take several days to show)
Open Book fx
Intertrochanteric frx
Hip Fx
Hip fracture classifications most
often are based on their anatomic
locations: head, neck,
intertrochanteric, trochanteric, and
subtrochanteric
Hip & Proximal Femur Fxs
Femoral head fractures
These usually are associated with hip dislocations. Superior femoral head
fractures normally are associated with anterior dislocations, while inferior femoral
head fractures are associated with posterior dislocations.
Type 1 - Single fragment fractures
Type 2 - Comminuted fractures
Femoral neck fractures
Type 1 - Stress fractures or incomplete fractures
Type 2 - Impacted fractures
Type 3 - Partially displaced fractures
Type 4 - Completely displaced or comminuted fractures
Intertrochanteric fractures
Type 1 - Single fracture line; no displacement; considered stable
Type 2 - Multiple fracture lines or comminution; displacement; unstable
Trochanteric fractures
Type 1 - Nondisplaced fractures
Type 2 - Displaced fracture; greater than 1 mm displacement for greater
trochanteric fractures and greater than 2 mm displacement for lesser trochanteric
fractures Subtrochanteric fractures
Stable - Bony contact of medial and posterior femoral cortices
Unstable
Femoral Head

Femoral Neck

Intertrochanteric fx

Trochanteric fx
Hip & Proximal
Femur fx

Leg shortened and


externally rotated
Hip Dislocation
MC is posterior
dislocation
Due to dashboard
Aseptic necrosis hips
Xray changes
Flattening, irregularity, sclerosis of
superior aspect femoral head(late)
Early findings on MRI/bone scan
Caused by trauma and chronic steroid use
Aseptic necrosis of the hips
Slipped Capital Epiphysis
Cause unknown
Does not occur before age 9 yo
Overweight teenage male
Radiographic dx
Thickened epiphyseal plate
Medial displacement of the femoral head
relative to the femoral neck
Lateral and frog leg views used for dx
Slipped Capital Epiphysis
Osgood - Schlatter disease
Traumatic tibial lesion in children
Avultion fracture of the anterior tibial
tuberosity
Frequent in active boys paticipating in
sports
Pain present
Age 10-15 yo
Heals with rest
Osgood - Schlatter disease
Legg-Perthes disease(aseptic necrosis
of the femoral head)
Boys more than girls
Limp + pain + limited ROM of the hip
Irregularity , sclerosis and fragmentation of
epiphysis
Resulting deformity with OA after a few
decades
Legg-Perthes disease(aseptic necrosis
of the femoral head)