1. Orthopedic Alerts in Primary Care
Kristine Campagna, DO
Latham Medical Group
September 8, 2012

2. Objectives Review frequently missed orthopedic diagnoses
Review criteria for ordering imaging in acute back pain, knee injury and ankle sprain

3. Distal Biceps Tendon Rupture

4. Epidemiology Data on incidence is scant
1.2 per 100,000 patients per year (Miyamoto et al)
Dominant arm of male patients between y/o
Smokers 7.5 times greater risk of injury than nonsmokers
Distal Biceps Rupture

5. Etiology Hypovascular Mechanical
Lack of blood supply to the distal biceps predisposed to rupture
Mechanical
The pronated forearm decreases the available space for the tendon between the lateral border of the ulna and the radial tuberosity causing impingement
Thought that hypovascular and mechanical mechanisms are reasons for rupture at musclotendinous junction
Lack of blood supply to distal biceps tendon leads to rupture
Distal Biceps Rupture

6. Anatomy Supination and flexion of forearm
Innervated by Musculocutaneous Nerve
Long head tendon originates intra-articularly at superior gleniod tubercle
Short head tendon originates at coracoid process
Two heads merge at level of deltoid tubercle and insert onto the radial tuberosity
Bicipital aponeurosis merges with the fascia and inserts onto the ulna
Distal Biceps Rupture

7. Anatomy
Distal Biceps Rupture

8. Mechanism of Injury Usually during a specific traumatic event
Unexpected extension force applied to flexed elbow
Eccentric contraction
Tearing sensation in antecubital fossa
Distal Biceps Rupture

9. Physical Exam Loss of normal biceps contour
Obvious deformity may be present
Weakness with elbow flexion marked weakness with forearm supination
Rupture may be missed if aponeurosis intact
Distal Biceps Rupture

10. Special Tests Hook Test Biceps Squeeze Test
Insert finger under the lateral edge of biceps tendon in antecubital fossa when elbow flexed at 90°
Biceps Squeeze Test
Similar to Thompson test
Squeeze biceps to elict forearm supination
Not medial edge-do not want to mistake the aponeurosis for the distal tendon
Distal Biceps Rupture

11. Imaging MRI can help delineate if partial tear or severe tendinopathy
Distal Biceps Rupture

12. Treatment Referral to Orthopedics for surgical intervention
Unrepaired distal biceps tendon rupture (Miyamoto et al)
Mean supination and flexion strength 74% and 88%, respectively, compared to contralateral arm
Supination strength worse if the dominant arm is injured
18 patients with mean of 59 mos after injury
Biceps Injury

13. Scaphoid Fracture

14. Epidemiology Most commonly fractured carpal bone 1o% of hand fractures
60%-70% of all carpal fractures
1.21/1000 person years
Males and whites have a higher relative risk
20 to 24 year olds highest incidence
Scaphoid Fracture

15. Anatomy Only carpal bone that bridges proximal and distal rows
80% of the surface is covered by cartilage, which limits ligamentous attachments and vascular supply
scaphoid is the largest bone of the proximal carpal row and is located on the radial aspect of the hand just distal to the radius itself (diagnostic image 1A and figure 1 and figure 2 and figure 3 and figure 4). In lateral profile, the scaphoid is shaped like an hourglass. The scaphoid articulates with the trapezium, trapezoid, capitate, and lunate. The radioscaphoid and scapholunate ligaments anchor the scaphoid proximally. The radial collateral ligament attaches to its lateral surface.
Scaphoid Fracture

16. Anatomy
Palmar carpal branch of radial artery supplies blood distally and then proceeds proximally
Blood supply to distal pole is tenuous and can be interrupted by a fx, increasing the risk of non union
Scaphoid Fracture

17. Classification of Fractures
Distal third (distal pole)-10%
Central third (waist)-65%
Proximal third (proximal pole)-15%
8% at tuberosity (protuberance at distal palmar aspect)
Scapoid Fracture

18. Mechanism of Injury Direct axial compression
Hyperextension of the wrist with a fall on outstretched hand (FOOSH)
DF >95degrees, the waist in the midbody of the scaphoid is forced against the dorsal lip of the distal radius
Scaphoid Fracture

19. Physical Exam
Pain in radial aspect of wrist, often just proximal to 1st metacarpal
+/- swelling
Focal tenderness
Volar prominence distal wrist crease for distal pole fractures
Anatomic snuffbox for waist fractures
Just distal to Lister’s Tubercle
Anatomic Snuffbox-extensor pollicis longus tendon medially and extensor pollicis brevis and abductor pollicis longus tendons laterally
Lister’s Tubercle-a longitudinal bony prominence of the distal radius located just to the ulnar side of the extensor carpi radialis tendon
Scaphoid Fracture

20. Plain Radiographs PA
Scaphoid Fracture

21. Plain Radiograph
True Lateral
Scaphoid Fracture

22. Plain Radiograph Scaphoid view
AP with 30 degrees supination and ulnar deviation
Plain x-rays are limited to detect scaphoid fractures esp at time of injury
Scaphoid Fracture

23. Management of Suspected Fracture
Immobilization in a short-arm thumb spica splint or cast for 7-10 days followed by reimaging with x-rays
May result in 75-90% of patients being immobilized for a week or more with only a soft tissue injury
Repeat imaging at 3-5 days using Bone Scan, CT or MRI
MRI after x-rays
Scaphoid Fracture

24. Indications for Surgical Referral
Displacement >1mm
Fracture associated with an increased tilt of lunate
Carpal instability or dislocation
Nonunion during follow-up
Osteonecrois
Possible scapholunate dissociation
Dissociation rupture of scapholunate ligament seen on clenched fist view with + Terry Thomas sign
Biceps Injury

25. Physeal Injuries

26. Physeal Anatomy
Growth plate or physis represents a major anatomical difference between adult and pediatric bone
Growing long bones composition
Diaphysis (shaft)
Metaphysis (where the bone flares)
Physis (growth plate)
Epiphysis (secondary ossification center)
Biceps Injury

27. Physeal Anatomy
Physeal Injuries

28. Physis Anatomy Represent a weak point in pediatric bone
Third zone (zone of hypertrophic cartilage)
In infancy and early childhood, physis is thick and epiphysis is mostly cartilaginous
Shock is absorbed and transmitted to the metaphysis
During adolescence, the epiphysis begins to ossify and forces are less absorbed
Shock is transmitted to the physis
The same injury mechanism causing a ligamentous injury in adults (sprain or strain) in more likely to cause a bone injury in children
Physeal Injuries

29. Fracture Pattern
Tensile strength of pediatric bone is less than that of the ligaments
Physis separates or fractures before disruption or “spraining” of an adjacent ligament
Physeal Injuries

30. Fracture Pattern
Most commonly involve distal growth plates of radius and ulna
Girls-between ages 9-12
Boys-between ages 12-15
Growth arrest, permanent decreased range of motion and angular deformity
30% cause a growth disturbance (premature closure and unilateral long bone shortening)
Tell story about young boy with injury to proximal tibia
Physeal Injuries

31. Fracture Classification
Salter-Harris Classification
S (“Straight across”)- Type I low risk for injury
A (“Above”)- Type II
L (“Lower” or “BeLow”)- Type III
T (“Through”) – Type IV
E (“End”) or ER (Erasure of the growth plate”) – Type V (high risk for growth plate injury) R
Biceps Injury

32. Slipped Capital Femoral Epiphysis
SCFE

33. Epidemiology 10.8 cases per 100,000 children
More common in boys and African-Americans and Pacific Islanders
Average age of diagnosis 13.5 for boys and 12 for girls
Bilateral presentation 18%-50% of patients
Some patients present sequentially (hips affected within 18 mos of each other)
SCFE

34. Etiology Obesity- 63% have a weight 90th percentile or higher
Growth surges
Endocrine disorders-hypothyroidism, growth hormone supplementation, hypogonadism and panhypopituitarism
Consider in unusual presentations-younger than 8, older than 15, underweight
SCFE

35. History and Examination
Hip, groin, thigh or knee pain and walks with a limp
Pain with internal rotation of the hip with decreased range of motion
May be pain with hip abduction and flexion
History of trauma to the area is rare
SCPE

36. Radiographs
Lateral Frog leg view AP
SCFE

37. Treatment
Urgent referral to an Orthopedic Surgeon for pinning to prevent progression of the slip
SCFE

38. Acute Low Back Pain

39. Epidemiology
Back pain accounts for 2.5% of medical visits resulting in 15 million office visits
Cost of LBP in the US exceeds $100 billion per year
75% of the total cost is attributable to fewer than 5% of patients with LBP
LBP

40. Epidemiology
Many cases are self-limited and resolve with little intervention
31% of patients with LBP will not fully recover within 6 months
Recurrent back pain occurs in 25-62% of patients within 1-2 years
33% moderate pain
15% severe pain
LBP

41. Risk Factors Smoking Obesity Older age Female gender
Physically strenuous work
Sedentary work
Low educational attainment
Worker’s Compensation insurance
Job dissatisfaction
Psychological factors
Somatization disorder
Anxiety
depression
LBP

42. Differential Diagnosis
Compression fracture
Herniated nucleus pulposus
Lumbar strain/sprain
Spinal stenosis
Spondylolisthesis
Spondylolysis
Spondylosis (degenerative disc or facet joint arthropathy)
Connective tissue disease
Inflammatory spondyloarthropathy
Malignancy
Vertebral discitis/osteomyelitis
LBP

43. Differential Diagnosis
Abdominal aortic aneurysm
Gastrointestinal conditions
Pancreatitis, peptic ulcer disease, cholecystitis
Herpes aozter
Pelvic conditions
Ednometriosis, pelvic inflammatory disease, prostatitis
Retroperitoneal conditions
Renal colic, pyelonephritis
LBP

44. History Is there evidence of systemic disease?
Is there evidence of neurologic compromise?
Is there social of psychological distress that may contribute to chronic, disabling pain?
LBP

45. Red Flags History of cancer, especially cancer metastatic to bone
Recent significant trauma, or milder trauma age > 50
Unexplained weight loss
Unexplained fever
Immunosuppression
Intravenous drug use
Osteoporosis, prolonged use of corticosteroids
Age >70
Focal neurologic deficit progressive or disabling symptoms
Duration greater than 6 weeks
American College of Radiology
LBP

46. Physical Examination Straight leg raise Crossed straight leg raise
Positive for L4-S1 nerve root if radiated pain below the knee
Crossed straight leg raise
Positive when lifting unaffected leg reproduces pain
Seated straight leg raise
Reverse straight leg raise (extending hip and flexing knee in prone position)
Positive for L3 nerve root pain if pain into anterior thigh
SLR-raise leg with ankle in DF, positive when pain is reproduced between 10 and 60 degrees of elevation
LBP

47. Anterior/medial thigh Patella Above L2-L3 L2-L3 L3-L4
Disc Herniation
Affected Nerve Root
Motor Deficit
Sensory Deficit
Reflex
Central
Para
central
Lateral L3
Hip Flexion
Anterior/medial thigh
Patella
Above L2-L3
L2-L3
L3-L4 L4
Knee extension
Anterior leg/medial foot
Above L3-L4
L4-L5 L5
DF/great toe
Lateral leg/dorsal foot
Medial hamstring
Above L4-L5
L5-S1 S1 PF
Posterior leg/lateral foot
Achilles tendon
Above L5-S1
None
98% of clinically important disc herniations occur at L4-5 and L5-S1
Absent ankle reflexes becomes increasingly common with age- 30% y/o nearly 50% y/o

48. Radiographs
Imaging is not warranted for most patients with acute low back pain
Reserve imaging for patients with severe or progressive neurologic deficits or when serious underlying conditions are suspected
If clinical improvement has not occurred after 4-6 weeks, AP and lateral radiographs may be useful
Young women-Gonadal radiation for a 2 view xray of back is equivalent to radiation exposure from a CXR taken daily for more than 1 year
Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific LBP-usually do not change management
LBP

49. MRI Indicated for progressive neurologic deficits
High suspicion of cancer or infection
Persistent back pain more than 12 weeks
Persistent symptoms due to a lumbosacral radiculopathy who have not responded to conservative treatment
LBP

50. Indications for Referral
Cauda equina sydrome
Blowel and bladder dysfunction (urinary retention,) saddle anesthesia and B/L leg weakness and numbness
Suspected spinal cord compression
Progressive or severe neurologic deficit
LBP

51. Acute Knee Injury

52. Ottawa Knee Rules Age 55 years or older Tenderness at head of fibula
Isolated tenderness of patella
Inability to flex knee to 90°
Inability to walk 4 weight-bearing steps immediately after the injury and in the emergency room
Knee Injury

53. Ottawa Knee Rules Retrospective chart review
Sensitivity 92% and specificity 57% for knee fracture
Prospective validation of rules published in 1996
100% sensitive for identifying knee fractures
If decision rules were negative, probability of a knee fracture was 0%
Knee Injury

54. Acute Ankle Injury

55. Ottawa Ankle and Foot Rules
Tenderness at posterior edge or tip or either malleolus
Tenderness in mid foot zone and at base of 5th metatarsal or navicular
Inability to weight bear (4 steps) immediately after injury and in the ER or physician’s office
Validated in children
Ankle Injury

56. Ottawa Ankle and Foot Rules
Ankle Injury

57. Ottawa Ankle and Foot Rules
Nearly 100% sensitive for detecting fractures in adults and children as young as 5 years
Negative findings eliminate need for x-rays
Specificity 30%-50%
Positive findings do not necessarily indicate that a fracture is present but do indicate that xrays are needed to confirm or rule out fractures
Ankle Injury

58. Questions