MSK KEY CONCEPTS ASSIGNMENT:

1. What is the difference between septic arthritis and osteomyelitis?

Septic arthritis is a medical emergency because it can destroy the joint. Osteomyelitis is usually
not an emergency.
Risk factors:
Septic Arthritis: Extremes of age, chronic debilitating disease, IVDA, Prosthetic joint/surgery,
chronic arthropathies.
Osteomyelitis: Sickle cell disease, DM, URIs in children
Diagnosis:
Septic Arthritis: Arthrocentesis (joint fluid aspirate is definitive diagnosis)
Osteomyelitis: Bone aspiration is gold standard.
Clinical manifestations:
Septic Arthritis: Joint involvement: single, swollen, warm, painful joint, tender to palpation
Osteomyelitis: Local signs (inflammation/infection, pain over the involved bone.
Management:
Osteomyelitis is managed with antibiotics for 4-6 weeks (at least 2 weeks via IV). Septic arthritis
is managed with a 2-4 week course of antibiotics.

2. List 5 ways we can test for nerve injury

Electromyography, which records electrical activity in muscles.
Sensory exam
Reflexes
Sharp and dull
Motor skills by testing ROM
Hearing and speech
Balance and coordination

3. List 5 ways we can test for vascular injury

Perfusion
Capillary refill
Temperature
Arterial pulses assessment
Pulses
Pitting edema
Auscultation of carotid artery for bruits

4. List 5 MSK injuries that are likely to have vascular injury.

Knee (tibial-femoral) dislocation can cause popliteal artery injury in 1/3 of patients.
Elbow dislocation can cause brachial artery injury.
Pelvic fracture can cause vascular injury (bleeding)
Hip dislocation can cause bleeding
Femoral condyle fractures can cause popliteal artery injury.
 Thoracic outlet syndrome (i.e. physical trauma from a car accident) can cause vascular
compression (swelling and discoloration of the arm)

5. List 5 MSK injuries that are most likely to have nerve injury.
Supracondylar humerus fracture can cause median nerve and brachial artery injury
(Volkmann ischemic contracture) and radial nerve injury
Olecranon fracture can cause ulnar nerve dysfunction.
Monteggia fracture can cause radial nerve injury (may develop wrist drop)
Elbow dislocation can cause median/ulnar/radial nerve injury.
Colles fracture can cause median nerve compression.
Pelvic fracture can cause sciatic nerve damage
Hip dislocation can cause sciatic nerve injury.
Knee dislocation can cause peroneal or tibial nerve injury
Femoral condyle fracture can cause peroneal nerve injuries.
Thoracic outlet syndrome (i.e. physical trauma from a car accident) can cause nerve
compression (pain/paresthesia to the forearm, arm and/or ulnar side of the hand)

6. How do you know if a fracture needs a cast or surgery?

In general, a surgery is needed when a fracture is fully out of place (displaced). Other cases
that need surgery are in an open fracture where the bone goes through the skin or when
the joint isn’t properly functioning after splinting or casting.

More specifically:
It depends on the fracture. For example, in a clavicle fracture if it occurs in mid 1/3 (arm
sling), if it occurs in proximal 1/3 (needs ortho consult)
In the case of several other fractures such as in Supracondylar humerus, radial head,
olecranon, ulnar shaft, patellar fracture, tibial plateau fracture, it depends on whether
they’re displaced (need ORIF) or if they’re nondisplaced (need just a splint).
Also, fractures that are unstable such as Monteggia and Galeazzi need ORIF.
There are fractures where the decision to perform surgery depends on the angulation. For
example, a boxer’s fracture that’s over 40 degrees needs surgery.
There are cases where perform surgery in refractory cases such as in Carpal tunnel
syndrome.
Some fractures have a high risk of complications (nerve or vascular injuries) which require
immediate surgery such as in femoral condyle fractures.

7. Which fractures get a splint and/or cast?

Splint:
Nondisplaced supracondylar humerus fracture
Nondisplaced olecranon fracture
Achilles tendon rupture
Stress fracture
Sugar tong splint
Humeral shaft fracture
Colles fracture

Radial gutter splint:

Scapholunate dissociation

Ulnar gutter splint:

Boxer’s fracture

Thumb spica splint:

Gamekeeper’s thumb
Bennett fracture
De Quervain tenosynovitis

Volar splint:
Carpal tunnel syndrome

Posterior splint:
Ankle dislocation

Cast:
Nondisplaced patellar fracture
Nondisplaced tibial plateau fracture
Pseudojones fracture (walking cast)
Lisfranc injury (non-weight bearing cast)
Ulnar shaft fracture

Brace:
Lateral/medial epicondylitis

Immobilization:
Posterior glenohumeral shoulder dislocation
Cubital tunnel syndrome
Lunate fracture

Sling immobilization:
Acromioclavicular joint dislocation

Arm sling:
Clavicle fractures
Non displaced Radial head fracture
 Knee immobilizer:
Patellar and quadriceps tendon ruptures

8. Which fractures always need surgery?

Anterior and Posterior glenohumeral shoulder dislocation need a reduction

A displaced supracondylar humerus fractures need ORIF
A displaced radial head fracture needs ORIF
A displaced olecranon fracture needs ORIF
A displaced ulnar shaft fracture needs open reduction and internal fixation
Monteggia fracture needs ORIF
Galeazzi fracture is unstable and needs ORIF
Radial head subluxation needs a reduction
An elbow dislocation needs an emergent reduction.
A displaced scaphoid fracture needs ORIF
An unstable or comminuted Colles fracture needs ORIF
A lunate dislocation is unstable and needs ORIF
Gamekeeper’s thumb requires a referral to hand surgeon because it affects pincer function
A Boxer’s fracture that’s over 40 degrees needs ORIF
Bennett fracture is unstable and needs ORIF
A Salter-Harris type IV and V need reduction
A pelvic fracture needs ORIF
A hip fracture needs ORIF
A grade III collateral ligament injury needs surgical repair.
A posterior cruciate ligament injury almost always treated operatively.
A displaced patellar fracture needs surgery.
A patellar and quadriceps tendon rupture requires surgical repair within 7-10 days.
A patellar dislocation requires a closed reduction
A knee dislocation requires immediate orthopedic consult and prompt reduction via
longitudinal traction.
A femoral condyle fracture requires immediate orthopedic consult and ORIF.
A displaced tibial plateau fracture requires ORIF
An ankle dislocation requires closed reduction and ORIF.
A Pilon fracture requires ORIF
A cauda equina is a neurosurgical emergency.
A spinal compression fracture requires neurosurgery consult, analgesics +/-
kyphoplasty/vertebroplasty.
Scoliosis over 40 degrees require surgical correction.
Compartment syndrome requires a fasciotomy
Osteosarcoma needs limb-sparing resection (if not neovascular); radical amputation (if
neovascular)
Chondrosarcoma requires surgical resection.
9. List 3 MSK injuries that do NOT need an x-ray.
Carpal tunnel syndrome, de Quervain tenosynovitis
Ankle sprain
Lumbosacral sprain/strain
Morton’s neuroma, thoracic outlet syndrome (need MRI, not an x-ray)

10. List the three main drugs, in order, that we use to manage rheumatoid illnesses.
NSAIDS for inflammation
Methotrexate to help with progression of disease.
Steroids to depress immune system

11. What are the differences between SCFE and Legg Calve Perthes disease?
Legg-Calve-Perthes disease:
MC in children 4-10 y, low incidence in African-Americans
Clinical manifestation: Painless limping
Management: Observation (self-limiting with revascularization within 2y)
Slipped capital femoral epiphysis:
MC in 7-16 y, obese, African-American
Clinical manifestation: hip, thigh or knee pain with limp.
Management: non weight-bearing with crutches → ORIF (↑risk of avascular necrosis)

12. Which spine injuries require surgery?

Cauda Equina syndrome (neurosurgical emergency)
Spinal compression fracture (kyphoplasty/vertebroplasty)
Scoliosis over 40 degrees requires surgical correction.

13. List all the MSK disease that are medical emergencies AND why they are medical
emergencies.
Hip dislocation because It can cause avascular necrosis or sciatic nerve injury, DVT, bleeding.
Femoral condyle fracture because of peroneal nerve injury or popliteal artery injury risk.
Knee (tibial-femoral) dislocation because of the popliteal artery rupture risk
Cauda Equina syndrome because of saddle anesthesia, decreased anal sphincter tone,
compression of several nerve roots of the cauda equina.
Septic arthritis because it can rapidly destroy the joint.
Supracondylar humerus fractures (displaced) because of median nerve and brachial artery
injury.

14. What three MSK injuries have the highest risk of DVT?
Pelvic fracture
Femur fracture
Hip fracture

15. What is the difference between osteomalacia and osteoporosis?

 In osteoporosis, the bones are porous and brittle, whereas in osteomalacia, the bones are
soft. This difference in bone consistency is related to the mineral-to-organic material ratio.
In osteoporosis, there is decreased bone mass with a normal ratio of mineral to matrix. In
osteomalacia, the ratio of mineral to matrix is decreased (there is too much matrix relative
to the amount of bone)

16. What’s the difference between Paget’s disease and osteogenesis imperfecta?
Paget’s disease has an unknown cause (it’s thought to be genetic and environmental)
Osteogenesis imperfecta is autosomal dominant disease leading to defects in the gene that
encodes for type I collagen.
Paget’s disease is usually asymptomatic and the most common symptom is bone pain. In
Osteogenesis imperfecta there’s blue tinted sclerae and brown teeth.

17. What MSK conditions require antibiotics?

Osteomyelitis
Septic Arthritis
Reactive arthritis

18. What’s the difference between osteoarthritis and rheumatoid arthritis?

Osteoarthritis is due to articular cartilage damage and degeneration with obesity being a big
RF. RA is due to destruction by pannus (granulation tissue that erodes into cartilage and
bone) and the RF is females and smoking.
OA has evening joint stiffness, which decreases with rest and worsens throughout the day
and with changes in weather. RA is worse with rest and has morning joint stiffness that
improves later in day.
In OA, Acetaminophen is the preferred initial treatment in elderly but NSAIDS more
effective.
In RA, Methotrexate is first line and NSAID is used as first line for pain control.

19. List 3 questions you should always ask someone with a back injury?
Where is the pain, when did the pain first start, did the pain come suddenly or gradual,
what was the patient doing at the time of onset, does the pain radiate, any serious
associated symptoms (neurological deficits, urinary/bowel problems, weight changes)

20. When do we need an MRI vs a X-ray? Give 2 examples of injuries/conditions that need an
MRI.
MRI is used for soft tissue evaluation, ligament and tendon injury, spinal cord injury, brain
tumors, etc. X-Rays are used to examine broken bones (hard tissue)
Avascular necrosis (MRI without contrast is gold standard)
Spinal stenosis (diagnostic test of choice)
Herniated disc (test of choice)
Posterior cruciate ligament injury and meniscal tears (diagnosed with MRI)
21. A patient with a forearm injury comes into your office. What do you? List 8 steps, in order.
(Do not include introduce yourself, wash hands….. start with history, exam…. I’ve now given
you the first 2).
1. History: onset/duration of symptoms, mechanism of injury, location of pain, radiation of
pain, numbness or tingling, provoking/alleviating factors.
2. Exam: Inspect for swelling, erythema, bruising, range of motion, strength, palpation,
sensation, pulses.
3. I would create a list of differential diagnoses (supracondylar humerus fracture, radial head
fracture, olecranon fracture, ulnar shaft fracture, monteggia fracture, Galeazzi fracture, elbow
dislocation)
4. Provide patient with analgesics (NSAIDS or opioids depending on severity of fracture/pain)
5. Order imaging (X-rays of wrist, forearm, and elbow)
6. Immobilize the forearm with a splint.
7. Orthopedic consult (if diagnosis requires it)
8. Admit patient for ORIF (depending on type of fracture, i.e. Monteggia fracture, Galeazzi
fracture, etc)
9. If fracture can be treated by splint/casting alone, discharge patient with Rx for pain meds and
provide orthopedic referral.