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Orthopedic Alerts in Primary Care

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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

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

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