Musculoskeletal Diagnoses Not To Be Missed Bradford H. Stiles, MD, FAAFP Disclosures I have a horrible deep sea fishing addiction My golf handicap is my swing No financial disclosures What not to miss Scaphoid fracture Scapholunate dissociation Skier s thumb Jersey finger Central slip rupture Little Leaguer s elbow Distal biceps rupture Pectoralis major tear Complete rotator cuff tear SCFE Legg-Calve-Perthes Patella/Quad tendon tear Osteochondritis dessicans Achilles tendon rupture Lisfranc injury Jones fracture Cauda equina syndrome
Scaphoid fractures Most commonly fractured carpal bone MOI: FOOSH injury (also assoc w/distal radius, lunate and radial head fxs) 3 zones: distal pole, waist, proximal pole Waist: 80%, proximal pole: 15%, distal pole: 5% Tenuous blood supply from distal end only High incidence of non-union & AVN in more proximal fractures Presentation/exam Classic history May not have any swelling Tenderness at anatomic snuffbox Positive axial load test of 1 st MC Pain with flexion/extension
Normal radiographs Radiographs PA, lateral, oblique (standard) and scaphoid views Negative initial x-ray doesn t rule out a fx Rule of thumb: if positive hx/moi and snuffbox TTP, treat as fracture, reimage in 7-10 days Treatment Nondisplaced middle/proximal third fxsimmobilized in long arm thumb spicacast; distal third ND fxsmay be immobilized in short arm thumb spica cast Distal 1/3 fxs 4-6 weeks Middle 1/3 and waist fxs 10-12 weeks (may change to short arm thumb spica cast after 6 weeks) Proximal 1/3 fxs 12-20 weeks May consider ORIF for proximal 1/3 fractures All displaced fractures need Ortho referral Risk of proximal AVN & severe radiocarpal OA if not treated properly
Scapholunate dissociation Most common ligament injury of the wrist Commonly missed; long term complication is severe: radiocarpal OA MOI = FOOSH Exam: tender over S-L area; positive scaphoid shift (Watson s) test (palpable clunk during palpation of scaphoid tubercle while patient goes from flexion/ulnar deviation to extension/radial deviation) Radiographs: standard AP may be normal; need clenched fist view; > 3mm S-L gap is positive ( Terry Thomas, Leon Spinks, David Letterman sign); may have ring sign Refer to Ortho Hand surgeon; generally require reconstruction
Ring sign and scapholunate angle Skier s Thumb Sprain/tear of the UCL of the first MCP joint AKA Gamekeeper s thumb May have bony avulsion Get x-rays if possible before testing
Pain and swelling at site of UCL Stress testing of joint in 30 of flexion May need MRI to look for Stener lesion Stener lesion Proximal end of the UCL becomes trapped superficial to the adductor pollicis aponeurosis Requires surgical repair Treatment If Stener lesion not present, thumb spica splint for 4-6 weeks If Stener lesion is present, refer to Hand Surgery Long term complication from improper treatment is osteoarthritis
Jersey finger Flexor digitorum profundus tendon rupture/avulsion FDP flexes the DIP joint MOI: forced extension with active DIP flexion (e.g., grabbing a jersey) Ring finger most common Inability to flex DIP joint Tendon may retract into palm All require urgent surgical management Central slip avulsion of the extensor tendon MOI: forced flexion of extended PIP joint Swelling of PIP joint, tender on dorsal side Unable to extend PIP joint against resistance X-ray to assess for large avulsion Splint PIP joint in full extension (leave DIP/MCP joints free) for 6-8 weeks
Boutonniere deformity Late complication of central slip injury Lateral bands drift volar to rotation axis becoming PIP flexors with DIP hyperextension (proximal phalanx buttonholes dorsally Deformity presents after several weeks Usually requires surgery Biceps Tendon Rupture 90+% are proximal Distal ruptures require early diagnosis Majority require surgical repair due to significant loss of supination strength Usually acute injury DDx: anterior capsule strain, coronoid process fracture, lateral antebrachial cutaneous n. entrapment PE: biceps tendon not palpable in antecubital fossa
Distal Biceps Tendon Rupture X-rays to r/o avulsion fractures MRI to confirm complete tear Early surgical repair due to retraction/scarring Pectoralis Major Injury Internal rotator and flexor of humerus Two heads: sternal and clavicular Tear can occur at bony insertion medially, M-T junction laterally or in muscle belly (rare) MOI: usually acute pull/snap from heavy lifting Rupture of inferior sternal head easy to miss May see defect in power prayer position MRI useful if diagnosis is unclear Surgical repair is dependent on strength requirements for sport/occupation Surgical outcomes better with earlier repair, but late reconstruction is possible
Complete Rotator Cuff Tear Complete tears will often retract and scar down, making surgical repair difficult if delayed More common in adults > 40 years old Often diagnosed as tendonitis Obvious weakness with RC testing (empty-can, drop-arm or lift-off tests) Diagnostic injection can help to differentiate tear from tendonitis/bursitis Untreated complete tears increase risk of GH osteoarthritis Slipped capital femoral epiphysis (SCFE) Femoral head slips inferior and posterior to femoral neck Incidence 2/100,000 children; may be bilateral (20-40%) More common in boys (mean age 13 years) than females (mean age 11 years) Associated with period of rapid growth, obesity Highest risk group is African-American boys Present with painful limp; pain usually in groin but may be in anterior thigh or knee (referred pain) Radiographic diagnosis Klein s line, ice cream off the cone Surgery required
Legg-Calve-Perthes Avascular necrosis of femoral head leading to collapse and flattening of femoral head Etiology unknown Males >> females Most common in boys 4 10 years old Often painless, but will develop limp; easily diagnosed on x-ray Goal of treatment is containment of femoral head in acetabulum Bracing Physical therapy Blood supply generally returns over several months, leading to new bone growth In children under age 6 years old with appropriate treatment, greater chance of ending up with normal hip joint
Femoral neck stress fracture Often misdiagnosed or missed Extreme risk of displacement Result of overuse/repetitive stress Common in athletes, military recruits History of recent increased activity (frequency or intensity) Tension vs. Compression side Must get x-rays if suspicious; may take 2-4 weeks for x-rays to be positive Usually present with groin pain or anterior thigh pain with any weight-bearing activity
Further work-up required if x-rays negative but suspicious history Bone scan can be positive within 24 hours of injury MRI extremely sensitive Treatment is dependent on location, compression vs. tension side Nondisplacedcompression side stress fractures treated conservatively with NWB until fracture is healed (6-8 weeks); serial radiographs essential to monitor for any worsening All tension side stress fractures are treated surgically
Patellar/Quad Tendon Rupture Most common in 3 rd & 4 th decades of life Increased risk after ACL reconstruction using patellar tendon graft Risk factors: trauma, steroid use, quinolone use, DM, RA/SLE, chronic tendonitis Inability to fully extend leg; focal deformity often present X-rays may show avulsion off patella or patellar migration (inferior/superior); consider contralateral films for comparison Knee immobilizer (straight leg) and urgent Ortho referral Need to be repaired in first few weeks
Osteochondritis dissecans(ocd) Most common in the knee, but can also be seen in ankle, elbow or any large joint Repetitive microtrauma/overuse leads to subchondralbone death and subsequent articular cartilage fragmentation 20%-30% have bilateral involvement (knees) Radiographic diagnosis; MRI is the gold standard and used for classification
OCD MRI Classification 4 stages based on MRI Stage I: low signal intensity Stage II: hypointense rim (no separation of lesion) Stage III: high signal intensity with underlying cystic changes (instability) Stage IV: dislocation of fragment into the joint space OCD Treatment Stage I: non-operatively with restricted weightbearing x 6-8 weeks Stage II: Non-operative if growth plates still open; in adults it depends on the size of the lesion Stage III-IV: surgery Missed diagnosis can lead to permanent damage and early degenerative joint disease ACHILLES TENDON RUPTURE Classic patient: 30-40 y/o male playing basketball (or tennis) Classic history: pushing off, felt like I was shot in the back of my lower leg ; loud snap often heard across the court Rupture occurs in watershed area 2-6 cm above insertion
Palpable defect Swelling/ecchymosis possible Positive Thompson s test Imaging studies obtained to r/o avulsion fracture Diagnosis Thompson Test Treatment Casting vs. surgery Can treat non-operatively with serial casting starting in equinus; long-leg cast required for the first month Surgical repair allows for quicker weightbearing 6 months recovery time
LISFRANC INJURY Classic forced plantar flexion injury (trip down stairs) Midfoot injury Easily missed Beware of the burrito foot WB films required Radiographic findings can be very subtle Low threshold for MRI if exam suspicious Refer to Ortho foot/ankle specialist Midfoot DJD and chronic foot pain if missed
JONES FRACTURE Proximal 5 th MT diaphyseal fracture 0.5cm 1.5cm from the proximal tip of the 5 th MT Distinguish between tuberosity fractures and Jones fracture Jonesland is area of very poor vascular supply; high rate of non-union
Treatment Tuberosity avulsion fractures/stress fractures treated in walking boot or hard-sole shoe True Jones fracture requires either prolonged NWB cast immobilization (8-12 weeks) or surgical ORIF Missed diagnosis leads to nonunion and chronic foot pain Cauda Equina Syndrome Terminal end of the spinal cord is at L1-2 Below this spinal canal is filled with the L2-S4 nerve roots, or cauda equina( horse tail ) Syndrome results from sudden reduction in volume of lumbar spinal canal Central disc herniation Epidural abscess or hematoma Trauma/fracture with retropulsion Onset may be sudden or over hours Symptoms Pain out of proportion; radicularpain/numbness bilaterally but worse on one side Saddle anesthesia Lower extremity weakness/paralysis Urinary or bowel incontinence or urinary retention Surgical emergency STAT MRI STAT spine surgery evaluation Missed diagnosis can lead to permanent nerve damage and paralysis
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