Diagnostic ImagingLecture 3Musculoskeletal

Musculoskeletal InjuriesMusculoskeletetal 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 ImagingMajority by plain radiographAP and Lateral projectionsOblique views for trauma involving joints, hands and feetCT - fine bone structure ( skull,spine and pelvis)MRI - evaluation of soft tissueNuclear medicine - bone metastases, differentiate cellulitis from osteomyelitis and occult trauma (stress fractures)

Skeletal ImagingMost bone lesions are obvious on clinical history>95 % bone films are obtained for:Evaluation of traumaEval. ArthritisEval. Degenerative conditionsMetastases

SprainsSprains are ligament injuries. Ligaments attach bone to boneLigaments 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.

Sprains1rst degree - joint pain / tenderness - no laxity

2nd degree - joint laxity present - pain and tenderness

3rd degree - ligament broken - unstable joint

SprainsMost 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.

StrainsA strain is the tearing of a muscle-tendon unit. termed tendonitisacute or chroniccaused by overuse or a single episode of overactivitypain results from minor tears in the tendons, from accumulated injuries (repetitive micro-trauma) that outpace the bodys ability to repair itself.

Strainsmay 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.

TerminologyFracture 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

Fracturedisplacement

FractureAngulation dorsal volar

FractureRotation

FractureBayoneting

FractureDistraction

FractureOblique

FractureGreenstick

FractureTransverse

FractureComminuted

FractureSpiral

FractureDislocation

FractureNonunionMalunion

FractureAvulsion

FracturesFractures 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 fracturesGrade 1: wounds < 1cm in length Grade 2: wounds > 1cm in length but clean w/o devitalization of tissueGrade 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 DescriptionFractures are further described based on:LocationPatternDisplacement

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 PatternThe 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 PatternSpiral 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 PatternAn 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) FracturesGrowth 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 ClassificationType 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 managementThe three principles of fracture care involve: 1) Reduction of deformity

2) Maintenance of reduction 3) Rehabilitation of function

Closed reductionReduction Closed OpenClosed reduction: involves the manual manipulation of the fracture into a functional position.traction is applied deforming forces are reversed realign the bone fragments.

Open reductionopen 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 alignmentMaintaining 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 painprevent 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 castingSplinting 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 castingMany 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.

ComplicationsCommon complications of musculoskeletal injuries:ARDS (fat embolism)DVTAtelectasisNerve compressionOsteomyelitis

Shoulder

Normal

Acromioclavicular (AC) separation (separated shoulder)Mechanism of injury- fall onto point of shoulderIf 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 intactGrade II:Rupture of AC ligament and joint separationGrade III:Coracoclavicular and AC ligaments ruptured with wide separation of jointTx:Grade I-II: sling, ice x 2 wks then ROMGrade III: sling, ice x several wks until pain subsides, then ROM & strengthening vs. surgical repair

Anterior Glenohumeral Dislocation Shoulder dislocationMechanism of injury:From external rotation & abduction force on humerusFrom a direct posterior blow to proximal humerusFrom a posterolateral blow on the shoulderExam:Space underneath acromion where humeral head should liePalpable anterior mass representing humeral head in anterior axillaTx:Closed reductionImmobilization in internal rotation

Shoulder dislocation

------Normal

Shoulder dislocation->

Anterior dislocation

(Much more common than posterior dislocation)

Posterior dislocation

Anterior Glenohumeral Dislocation Complications2 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 fractureMost common bone fracturedWeakest aspect is junction of middle/distal thirds Look for Tenting of the skinClass 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 FracturesProximal Humerus Fractures:Neer classificaton:Non-displaced fractures: are displaced less than 1cm or angulated

Proximal Humerus FractureThe vascularity is at risk with anatomical neck fracturesMost common mechanism of injury= FOOSHSigns & symptoms:Pain, swelling, tenderness Tx:For nondisplaced fxs= sling, begin ROM exercises2 part/3 part fxs= closed reduction, sling, possible ORIFAbsolute indication for hemi-arthroplasty: 4 part fxs, non-reducible 3 part fxs

Midshaft Humerus FracturesSigns & Symptoms:Arm pain, swelling, deformityThe arm is shortened with gross motion & crepitus on gentle manipulationXR:AP/lat c shoulder & elbowTx:Coaptation splintCarefully molded plaster slab placed around medial & lateral aspects of arm, extending from axilla around elbow & over deltoid & acromion x 2 wksChange to Sarmiento brace @ 2 wksMay require ORIF with plate/screw or intramedullary nailing

Midshaft humerus fx

Elbow FracturesMonteggia FractureUsually a fx of the proximal Ulna with anterior dislocation of the radial headMOI:Forceful pronation or direct blow to dorsum of ulnaH&P:Pain & h/o trauma, may have obvious deformityXR:AP/lat/obliqTX:Hematoma block, reduction, long arm cast or splintMay require ORIF

Galeazzi Fracture/dislocationinvolving 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 FractureMOI:Fall forward with elbow extended, forearm pronatedPain localized to radial headXR:AP/lat/obliqIf fracture is subtle, look for fat pad, or sail signsTX:Types I, II, & III without mechanical block are treated with a sling and AROM x 3 wksAfter 3 wks d/c sling & begin aggressive PTFxs 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 FracturesPain @ elbow with h/o traumaXR:AP/lat/obliqManagementInitial: sling for comfortDefinitive: non-displaced fxs can be managed with posterior splint @ 90 degrees flexion x 2 wksOther fxs are managed with ORIF or percutaneous pinning & early motion post-operatively

Olecranon Fractures

Olecranon Fractures

Distal Humerus FractureSupracondylar fxs of the Humerus:Characterized by dissociation b/t diaphysis & condyles of distal humerus, frequently extended distally & involves articular surfaceCaused by FOOSH or direct blowPE:+ deformity, instability, crepitusXR:AP/lat/obliqManagement:Initial: alignment, immobilization, ice, long arm splintDefinitive: ORIF, early motion(Other fxs: transcondylar, medial condyle, lateral condyle)

The Wrist-Eight Carpal BonesSome Lovers Try Positions That They Cannot HandleProximal / Distal row from radial to ulnar positionScaphoid,Lunate,Triquetrum,Pisiform,Trapezium,Trapezoid,Capitate,Hamate+ Radius and Ulna

Movements at the wristRadial deviation (abduction)Ulnar deviation (adduction)FlexionExtensionSupinationPronationCombination of all of the above

Wrist DislocationsPerilunate, and Lunate dislocations are variations of the same injury Caused by hyperextension of the wrist (FOOSH)Exam:Note areas of ecchymosis, active ROM, neurovascular statusWhen dislocated, wrist appears shortened with a fullness over the dorsum or in the carpal tunnelAny movement produces painSwelling varies from barely perceptible to significant

Wrist DislocationsXR:Minimum 4 views: AP neutral, AP ulnar deviation, oblique, lateralTx:Reduce ASAP to minimize risk of median nerve injuryAxillary block or IV regional block provide adequate muscular relaxation.Apply traction for 5-10 min using finger trapsReduce & place in thumb spica plaster splint with wrist in neutral or slight palmar flexionPost reduction films are requiredMay Require surgery for adequate reduction

Perilunate dislocationPerilunate dislocation

Lunate dislocation

Distal Forearm Fractures1. Extension fractures: Colles FractureFx distal radius with dorsal angulation of distal fragment and associated fx of the ulnar styloidUsually 2* to FOOSHExam: swelling wrist, decreased ROM secondary to painXR:AP/true lateral/obliq- radius will be shortened

Colles fx

Colles fx

Distal Forearm Fractures (cont)Colles Fx (cont)Tx:Hang in finger trapsHematoma 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 siteWait several minutes until pain is decreased & reduce fxPlace in long arm cast (LAC) with wrist @ 20-30 degrees of flexion & ulnar deviationPost reduction films are necessaryIce, elevate above level of heart, NSAIDs, analgesia

Distal Forearm Fractures (cont)2. Non-displaced Distal Radius FxsRequire short arm cast (SAC) in neutral, ice, elevation, NSAIDS, analgesia3. Other common fxs:Smiths fxReverse Colles fxFracture of the distal radius with palmar (volar) displacement of the distal fragment.Die Punch FxIntra-articular distal radius fx with impaction of the dorsal aspect of the lunate fossaBartons FxDisplaced intra-articular lip fx of the distal radius May be assoc with carpal subluxationMay be dorsal or volar configurationExtends into radio-carpal joint

Smiths fx

Smiths Fx

Scaphoid FracturesMC fxd carpal boneThere is no direct blood supply to the proximal portion of the scaphoidTherefore, scaphoid fxs have a tendency to develop delayed union or avascular necrosisRemember the more proximal the fx line is in the scaphoid injuries, the greater the likelyhood of avascular necrosisMechanism of injuryForceful hyperextension of the wrist

Scaphoid FracturesExam: + snuffbox tenderness, radial deviation of wrist will probably elicit painXR:Obtain AP/lat/obliq/scaphoid viewsInitial plain xray may not demonstrate fx for up to 4 wksIf xrays are still negative at 10-14 days & pt is symptomatic, obtain bone scan for definitive diagnosisA bone scan will show an increase in uptake in fracture areaTx: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. Pisiform19. Radius 20. Ulna

Game Keepers ThumbSkiers ThumbInjury to the ulnar collateral ligament of the MCP joint of the thumbDestroys joint stabilityImpairs ability to pinchEvaluation:Stress ulnar aspect of the MCP joint by forcing thumb into radial abduction If there is 45 degrees at the ulnar aspect of the MCP joint, surgical repair is requiredClosed tx with a thumb spica cast or splint with the thumb slightly adducted may allow for healing of an incomplete tear

Distal Phalangeal Fractures1. Closed:Splint, Ice, Analgesia2. Open:Digital block c 1% lido local anesth.Irrigate? RongeurSterile repair (suturing) of nailbed, place nail as biological dressingXeroform gauze (betadine/petroleum imbedded gauze) & sterile gauze dressingSplintAntibiotics

Middle & Proximal Phalanx FracturesStable, 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 degreesFxs with rotational deformities may require closed or ORIF & casting/splintingUnstable fxs may require casting or percutaneous pinning with Kirschner (K) wiresMore recently these fxs are being internally fixed with plates & screws from small fragment sets

Finger dislocationReduceSplint

Metacarpal Neck FracturesMost 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 ExtremitiesSecond Part

Knee Standard Xray projections:AP eval.joint space narrowing / calcificationsLateral eval.Patella / effusionsSpecial viewsSunrise / merchant viewTangential / knee flexed/from top-downTunnel view Knee more flexed, looking through the tunnel created by the femoral condyles

KneeMost common reasons to order Knee X rays are: - trauma - DJD ( X rays findings)MRI soft tissues - tendons, ligaments, menisci, and cartilage

Knee

The KneeLigaments:Anterior Cruciate Ligament (ACL)Posterior Cruciate Ligament (PCL)Medial Collateral Ligament (MCL)Lateral Collateral Ligament (LCL)

Knee Knee effusion:Best seen on Lateral viewSuperior to PatellaAnterior to distal femurWater or blood Same density as muscleLook for anterior displacement of fat lineClinical examination superior to X ray

Knee soft tissue injuriesMost 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 jointMRI 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 medialThe ACL prevents anterior translation of the tibia

PCL-Originates on the medial femoral condyle and inserts on the tibia.Medial lateralThe PCL prevents posterior translation of the tibia

Medial Collateral Ligament(MCL)Originates on the medial femoral epicondyle and inserts on the proximal tibiaThe 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

MenisciCrescent 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 TearMost Common injury to the knee requiring surgeryMedial meniscal tears occur 3x more frequently than lateral meniscal tearsFrom acute trauma or chronic long term wear and tearLocked knee requires urgent intervention

Meniscal Tear Diagnosis

History: Locking, clicking soundcatching episodes / giving way episodespain with squatting / SwellingPhysical Exam:+ effusion+ joint line tenderness+ McMurrays sign

Meniscal TearTreatment:Meniscal repair may be achieved arthroscopically by suturing the torn meniscusThis may be an option if tear occurs in an area with blood supplyPartial meniscectomyArthroscopic removal of the torn meniscus

Ligament Sprains

Ligament sprains

Medial Collateral Ligament (MCL)SprainCaused by valgus force to kneeDiagnosis:+ 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:IceNSAIDSPhysical TherapyGrade III sprains may require surgical repair

Lateral Collateral Ligament (LCL) SprainCaused by varus force to knee UncommonDx:+ tenderness along LCL (Grade I-III)+ opening of lateral joint line with varus stress when knee is @ 30 degrees of flexionTx:Non-operative:IceNSAIDSPhysical therapy

Anterior Cruciate Ligament (ACL) SprainsCaused by twisting of knee while foot is firmly planted on groundHx:Patient hears a pop feels a tear and acute pain in kneeKnee may feel unstable with weight bearingAcute swelling at time of injury

Anterior Cruciate Ligament (ACL) SprainsDx:+ Lachman (20-30 degrees flexion, pull tibia anteriorly)+ anterior drawer (90 degrees)+ pivot shift with anterolateral instabilityArthrocentesis reveals hemarthrosisMRI >90% accurateTx: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-opIf stable = no surgery nec.

ACL tear

Posterior Cruciate Ligament (PCL) SprainCaused by hyperextension of knee or direct blow to anterior aspect of flexed knee (Dashboard)Dx:+ posterior drawerMRI >90% accurateTx:Physical therapySurgical reconstruction in patients who have high demand knees (athletes) and severe instability

Unhappy TriadThis 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 tear2. MCL tear3. Medial meniscus tear

Patellar Tendon RuptureMost frequently in patient

Patella tendon ruptureNotice superior appearing patellaNormal Knee

Patella Dislocation/ SubluxationLateral displacement of patellaAcute vs. recurrentReduction occurs with knee in extension+ patella apprehension testTx: mobilization and strengthening exercisesVs. Immobilization in cylinder cast x 6 wks Vs.Surgical repair

Patellar fractures Direct blow to patella fallDark lines across the boneSharp corners and edgesRepair by fixation pins and wire

Patellar fracture

Chronic Knee PainDJD OA vs RA -PEDecreased ROMNo systemic symptoms Plain radiographs for initial workup (standing)X ray findingsjoint 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 ReplacementIndicated for severe DJDFemoral condylar componentProximal tibial componentPatellar componentAP- may look like components are not touching plastic component not seen on XrayInfection and looseningBoth look as lucent space around screws and base of the implant

FootBones of the foot:7 tarsalsTalusCalcaneusNavicularMedial CuneiformIntermediate CuneiformLateral CuneiformCuboid5 metatarsalsrays of the foot14 phalanges

Plantar FasciitisPlantar 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 FasciitisContributing 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 FasciitisTx:Achilles stretching (tennis ball)massageRest from activitiesNSAIDSShock absorbing heel cupsAnkle orthosis (AFO) for recalcitrant casesAvoid cortisone injections

Hallux ValgusMost 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 featuresMore common in women Often bilateral Symptoms result from A bursa over metatarsal head = bunion Osteoarthritis of the first MTPJ

Hallux ValgusXray:Bilateral weight bearing AP/ lateral/ oblique footInitial Tx:Shoewear education/ modification (sneakers)Surgical Tx:Distal metatarsal osteotomy +/- internal fixation for mild deformity1st tarsal metatarsal arthrodesis (fusion) for hypermobile 1st ray

Lisfranc InjuryFracture and lateral dislocation of 2nd, 3rd,4th and 5th metatarsals relative to the tarsal bonesMOI: falling out of a saddle, foot caught on stirrup, or stepping into a hole with twisting of the footExam:+ tenderness at Lisfranc joint + swelling dorsallyXR:AP/ lateral/ oblique foot (weight bearing when possible): May reveal widening at jointTx:Reduced & treated with screw fixationNWB x 6-8 wks

Jones Fracture/Dancers fractureTransverse fracture of the 5th metatarsal at the junction of the proximal metaphysis & diaphysisPE:+ tenderness lateral aspect of foot+ swelling +/- ecchymosisXR:AP/ lat/ obliqTx:Short leg cast (SLC) Non-wt bearing (NWB) x 6wksFrequently fail to heal when treated non-operatively, especially in smokersSurg:ORIF

Jones fx

Avulsion Fracture of the base of the 5th MetatarsalPseudo-Jones fx/ dancer fx/ tennis fxOccurs when the insertion of the peroneus brevis is avulsed during forced inversion of the forefootExam:+ tenderness+ swelling at base of 5th metatarsal+/- ecchymosisXR:AP/lat/obliqTx:Short leg walking cast (SLWC) x 6 wks

Pseudo-Jones FractureDancer FractureTennis FractureAvulsion Fracture

Pseudo-Jones Fracture

Comminuted Fracture of proximal and/ or distal phalanx of great toeXR:AP/lat/obliqTx:SplintHard sole shoeIceBuddy tape

Fractures of phalanges of lesser toesXR:AP/lat/obliqTx:Buddy tapeIce NSAIDS

March FractureStress 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 traumaAlso seen in females with eating/exercising disordersExam:+ tenderness midshaft of the involved metatarsalPain with increased flexion or extension of toesPain subsides with rest

March FractureInitial XR:AP/lat/obliq weight bearing foot will be negativeFollow up XR:In 2 wks will show callus formationTx:Symptomatically with crutches or if patients occupation requires prolonged standing or ambulationSLWC x 3-4 wks

Stress fx

Calcaneus FracturesMay be intraarticular or extraarticularh/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 fxAlso do Xray of Lumbar spine due to associated fxsInitial management:SplintIceElevation

Calcaneus FractureTx:Non-displaced intraarticular fx= NWB 4-6 wksDisplaced intraarticular fx= ORIF, NWB x 6-8 wks, early motionMinimally displaced tuberosity fracture= NWB 3-6 wksDisplaced tuberosity fx= internal fixation, NWB 4-6wksSustentaculum tali= SLWC x 4-6 wksNon-displaced anterior process fx= SLWC x 4-6 wksDisplaced anterior process fx = ORIF

The AnkleBonesTibiaFibulaTalus

Obtain AP/lat/obliq to r/o fractureAnterior fat line displacement with effusion (Lateral view)

Ankle sprainsInversion injury= MC mechanism of injury / injures lateral structures of ankleMC 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/dayElevationNSAIDSWBAT c crutches prnEarly ROMstrengthening

Ankle fracturesMost common:Medial or Lateral malleolusSevere trauma trimalleolar fractureWhen severe associated ligament damage and subluxation of distal tibia over the talusStress views when NL Xray (standard) and high clinical suspicion of trauma

Bi - Malleolar fractureAnkle 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 FracturesCan involve any boneTalus fractures are rare - MVAccidentCalcaneous fracture hard to see in standard views order calcaneal viewPlace foot on film and shooting down along the back side of the ankle

Achilles TendinitisPain at achilles tendon, increased by running decreased by restPain is often worse following activity, rather than duringOften palpable thickening over tendon or peritendinous tissues

Achilles Tendon RuptureOccurs most commonly at narrowest portion of tendon approx. 2 inches superior to point of attachment to calcaneusMechanisms of injury:1. extra stretch applied to taut tendon2. forceful dorsiflexion with ankle in relaxed state3. direct trauma to taut tendon

Achilles Tendon RuptureC/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 outTx:1. surgical repair2. equinus walking boot x 8 wks followed by 2.5 cm heel for another 4 weeks

Tibial Shaft Fractures

Mechanisms of injury1. 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 FracturesInvolve proximal articular surface of tibiaExam:Pain localized to proximal tibia, +/- swellingImaging:AP, lateral kneeCT scan

Tibial Plateau Fracture Classification

HipXray viewsAP and frog legs (abducted)Lateral views hard to interpreteEvaluate the relationship of femoral head to the acetabulumLook for cortical discontinuitiesLook at trabecular pattern

Hip dislocationsFrom M V AccidentsMost common posterior dislocationOn AP - head of femur located superiorly and laterally displacedAnterior dislocation: inferior and medialLook for associated fracture fragments from the acetabulum

Hip dislocationPosterior dislocation:Head of the femur superior and laterally located

Anterior dislocation:Head of femur located inferiorly and medially to the acetabulum

Hip fractures90% of hip fracture either at: Femoral neck - OsteoporoticUnable to walk after a fallLittle deformityIntertrochanteric - post traumaticShorter leg in internal rotationStress frx dificult to detect in elderlyNondisplaced frx better seen MRI Bone scan ( may take several days to show)

Open Book fx

Intertrochanteric frx

Hip FxHip fracture classifications most often are based on their anatomic locations: head, neck, intertrochanteric, trochanteric, and subtrochanteric

Hip & Proximal Femur FxsFemoral 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 fracturesType 2 - Comminuted fracturesFemoral neck fractures Type 1 - Stress fractures or incomplete fracturesType 2 - Impacted fracturesType 3 - Partially displaced fractures Type 4 - Completely displaced or comminuted fracturesIntertrochanteric fractures Type 1 - Single fracture line; no displacement; considered stableType 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 NeckIntertrochanteric fx

Trochanteric fx

Hip & Proximal Femur fxLeg shortened and externally rotated

Hip DislocationMC is posterior dislocationDue to dashboard

Aseptic necrosis hipsXray changesFlattening, irregularity, sclerosis of superior aspect femoral head(late)Early findings on MRI/bone scanCaused by trauma and chronic steroid use

Aseptic necrosis of the hips

Slipped Capital EpiphysisCause unknown Does not occur before age 9 yoOverweight teenage maleRadiographic dxThickened epiphyseal plateMedial displacement of the femoral head relative to the femoral neckLateral and frog leg views used for dx

Slipped Capital Epiphysis

Osgood - Schlatter diseaseTraumatic tibial lesion in childrenAvultion fracture of the anterior tibial tuberosityFrequent in active boys paticipating in sportsPain presentAge 10-15 yoHeals with rest

Osgood - Schlatter disease

Legg-Perthes disease(aseptic necrosis of the femoral head)Boys more than girlsLimp + pain + limited ROM of the hipIrregularity , sclerosis and fragmentation of epiphysisResulting deformity with OA after a few decades

Legg-Perthes disease(aseptic necrosis of the femoral head)

***************************************************************************************************************************************Valgus deformity- knock-kneed, distal part of the legs deviated outwardVarus deformity bowed ledgged , distal portion of the legs deviated inward*************************************************Short length walking cast SLWC**Midfoot-metatarsals, forefoot -phalanges******************************