Case 5 year old with 2 weeks leg pain and now refusing to walk + Fevers, lower leg swelling, warmth Denies and history of trauma or wounds
Exam I: Swelling over entire tibia extending to foot P: Tenderness and warmth over tibia, no joint effusion R: Normal FROM of knee, hip, and ankle N: Normal strength/sensation S: None
X-ray/MRI
Osteomyelitis Localized tenderness and swelling Fever with acute cases Refusal to move limb or weight bear Hematogenous speard vs local penetration X-rays negative until 10-14 days Culture when possible Staph, strep pna, GAS, HIB, (Salmonella, TB)
Treatment IM/IV Diclox, Nafcillin, (Clindamyacin/Vancomyacin) IM/IV Chloramphenicol (sickle cell) Total 5-6 weeks of Antibiotics Can transition to oral once afebrile with continued clinical improvement May need surgical debridement if not resposive to 2-3 weeks of abx Rule out septic joint
Case 25 y/o female with fall onto outstretched hand Immediate medial wrist pain and swelling Pain with wrist and thumb motion No elbow pain
Exam I: mild swelling over anatomical snuffbox P: Tenderness over scaphoid bone R: Limited wrist and thumb ROM due to pain N: Normal strength and sensation S: Pain over sacphoid with thumb axial loading
X-rays/MRI
Scaphoid Fracture Always palpate snuffbox region Immobilize if +snuffbox TTP (occult?) Retrograde (poor) blood supply Thumb spica 6-8 weeks Beware of non-union, avascular necrosis
Case 18 year old boy with knee popped out Immediate pain and deformity Rapid swelling after reduction by extending his leg History of this 3 times in last year
Exam I: Swelling of knee joint, no deformity P: Tender medial patella and lateral condyle R: Limited knee flexion to 90 degrees due to pain N: Normal S: +Patellar apprehension, +2 patellar glide, normal ligamentous testing
Patellar dislocation
Treatment Treatment involves strenthening of supporting muscles (VMO, Gluteals, Core) Stretching of antagonistic muscles (hamstrings/it band) Stabilizer bracing PT to improve Bio-mechanics (avoid dynamic valgus)
Dislocations " Joint dislocations/subluxation usually related to weak supporting muscles and stabilizers " Shoulder/Patella most common " Dislocation requires reduction " Secondary surrounding soft tissue and bone injury
Dislocations " Immediate reduction best for dislocation (check for NV compromise, rule out Fracture) " Stabilization strengthening key after acute phase to prevent re-injury " High recurrence rate " Hyperlaxity, poor mechanics, weak stabilizers make high risk
Dislocations
Dislocations
Dislocation
Treatment
Soft Tissue Injuries " Strains- acute partial muscle tears " Sprains- acute partial ligament tears " Tendonitis- overuse " Contusions- acute trauma
Contusion
Recovery " Require relative rest " Anti-inflammatory measures " Vigorous rehabilitation for optimal RTP and prevent stiffness/tendonopathy/reinjury " Progressive, predictable rehab immediately after acute phase
Case 20 year old futball player felt knee pop when twisted knee trying to rapidly pivot Immediate pain followed by large swelling of joint Unable to walk without knee giving out
Exam I: Large swelling of knee P: Diffuse Tenderness, moderate effusion of knee R: Decreased Knee flexion due to pain/ swelling N: Normal strength/sensation S: +Lachman s, Anterior Drawer, Valgus Stress test
ACL Injury
Ligamentous Injury " Tears of joint collateral, cruciate, cartilagenous structures " Acute force mechanisms " Pop, pain, swelling, instability " Shoulder, Knee, Ankle most often affected " Joint Effusion very suspicious for internal ligamentous injury
Meniscus tear
Case 8 year old with displaced supracondylar elbow fracture Closed reduction attempted with acceptable alignment with subsequent casting 4 hours post reduction complains of increasing severe pain 5 hours complains of numbness and weakness of hand
Exam Swollen tight elbow and forearm Severe tenderness from elbow to hand Unwilling to move at elbow and wrist due to pain, and +increase pain with passive wrist ROM Strength 3/5 at wrist and hand, decreased sensation along entire hand; normal 2+ radial/ulnar pulses +increase pain with passive wrist ROM
Compartment Syndrome " Increase muscle compartment pressures " Usually due to fracture, dislocation, trauma " Compression of neurovascular bundle " PAIN, Paresthesia, Pulseless, Palor, Paralysis " Emergent reduction critical for salvage of limb
Case 17 year old s/p fall while downhill skiing Felt pop/crack in thigh followed by severe pain/disability Rapid thigh swelling, limb shortening Pain with any limb motion or manupilation Altered mental status and hypotension
Case I: Deformity and swelling of left thigh P: TTP most in distal femur, with step-off palpated R: Able to wiggle ankle/toes, Unable to tolerate any motion at hip or knee N: 2+ pedal pulses, normal sensation, CR 3-4 sec S: None given concern or Fx
Femur Fracture High impact mechanism Needs immediate treatment Traction, Immobilization, Orthopedic consult Follow blood loss, transfuse if needed Monitor for compartment synd
Case 21 y/o football player Knee pain and deformity after tackled Multiple pops heard Large effusion, severe pain, deformity Unable to bend knee
Knee Joint Dislocation High impact mechanism Tibia dislocated from femur All stabilizing ligaments of knee torn Emergent reduction necessary High rate of popliteal artery entrapment, compartment syndrome, lower limb ischemia
Case 17 y/o motor bike accident hit head to ground with axial load Normal mentation Reports neck pain Unable to move or feel below his neck
Exam I: No obvious deformity P: Tender C-spine with step offs at C7-8 R: Only can move neck; was not allowed N: No motor or sensory innervation below neck, normal pulses S: None
X-ray
C-spine " Injury mechanism? Mentation? " Neurologic compromise? " C-spine tenderness, step off? " Assess airway, breathing...circulation! " Secure C-spine for transport
Case
Case
Second Impact Syndrome
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