Orthopedic Clinical Pearls June 8, 2011

Case # 1 45 y/o man presenting with tearing injury to R elbow Pain settles in 15 minutes, movement normal No deformity, no contusion Movement, full ROM with minimal discomfort Normal neurovascular, power good Differential: intra-articular #, ligament, tendon?

The Acutely Injured Joint History Examination Investigations Differential Case 1 – power of supination = weaker with resistence, + Hook test, X-ray never bad ?MRI Diagnosis = distal bicep tear – surgical emergency

Case 2 25 y/o female “pop” with flexion rotation injury playing soccer Rapid swelling, restriction, decreased flexion, deformity, max. anterior medial, diffusely tender Differentials: acute tear, dislocation, large mensical tear, intra-articular # Examination: extensor mechanism intact, patellar alignment decreased, tender, stability testing limited by pain, can’t do lachman or ant/post drawer – if positive is a major injury

Case 2 continued X-ray, US no, CT no, MRI maybe later Dx: osteochrondrial intra-articular # with lipoarthosis = fat level present increased likely # - CT will show better

Case 3 65 y/o woman known OA minor twist of L knee When walking felt “pop” and increasing pain, swelling, decreased ROM, otherwise well Examination: decreased ROM flexion, no instability, fully extend Differentials: # osteophyte, infection, crystal synovotitis Investigation: x-ray, labs normal CBC, elevated CRP 9.9 – Joint aspiration Dx: pseudogout with ca pryophosphate crystals in aspirate

Acutely Injured Joint History Traumatic event Sense of pop, or tear or subluxation (something bad happened” Acute dramatic loss of function – locked, can’t weight bear Rapid swelling/effusion Neurovascular symptoms Immediate pain may subside Beware of escalating pain (compartment syndrome) Examination Deformity Swelling versus effusion Point of tenderness versus diffuse tenderness Ability to weight bear Neurovascular exam Range of motion Stability tests strength

Acutely Injured Joint continued Investigations X-ray always good CT Stress view x-rays Ultrasound MRI Differential Diagnosis Major ligament injury Intra-articular fracture Subluxation/dislocation Tendon disruption Loose body Inflammatory/Infectious

When to Refer? Something popped or tore Acute loss of function Locked joint Severe or escalating pain Neurological &/or vascular signs & symptoms are acutely present Significant swelling: effusion vs hemarthrosis vs extra-articular swelling Peri-articular or intra-articular fracture Any penetrating injury to joint Suspicion of infection Unstable joint If is doubt discuss with ortho **early intervention is best chance to restore function

QUESTIONS?