Musculoskeletal Review

Cody Malley PA-C, LAT, ATC

NCAPA Winter Conference

February 2017

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

SHOULDER

Anatomy • Four joints: SC, AC, GH, Scapulothoracic

Anatomy

• Rotator Cuff: Supraspinatus, Infraspinatus, Teres

Minor, and Subscapularis

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

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

Standard Views

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

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

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

Impingement

Neer’s Done passively, not actively

Hawkins’ Done passively, not actively

Rotator Cuff Disorders

Rotator Cuff Tear

Rotator Cuff Testing

Supraspinatus

Infraspinatus/Teres Minor

Subscapularis Subscapularis – Lift off test

Imaging

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

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

Anterior Shoulder Dislocations

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

Bankart Lesion

Hill Sachs Lesion

Posterior Shoulder Dislocations (GH Joint)

-Rare

-Epileptic Seizures

-Usually high velocity

-Often times has associated

trauma

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

Anterior Instability

Sulcus passive

Apprehension and

Relocation passive

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

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

SLAP lesion superior labrum anterior to posterior

“SLAP” lesion

AC Separation

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

AC Separation Types

AC Separation

Anterior SC (sternoclavicular)

Dislocations

• Anterior usually MVA

• PE: TTP SC joint, deformity

• Radiographs: AP, 40 degree cephalic view

• Usually conservative management o Sling, ROM

Posterior SC Dislocations

• Usually fall on flexed

and adducted

shoulder

• Can be life-

threatening

• Immediate referral and CT

• Closed reduction or

surgical reduction

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

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

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

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

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

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

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

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

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

ELBOW

Imaging • AP

o Even joint spacing

• Lateral

o Center of radius lines

up w/ center of

capitellum

“Fat pad sign”

• Anterior fat pad –

normal

• Posterior fat pad –

always abnormal

• Suggests intraarticular

fracture o Children – supracondylar fx

o Adults – radial head fx

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

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

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

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

Supracondylar Fracture – type II

Supracondylar Fx – type III

CRPP – closed reduction

percutaneous pinning

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

FOREARM, WRIST, AND

HAND

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

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