CT3 Musculoskeletal

training day
Mr C J Blakeley
A&E Consultant
Mayday Hospital
Programme for day
London Deanery CT3 Training Day
Thursday 27 th September
Postgraduate Medical Centre, Mayday Hospital

9.00am Registration and coffee

9.30am Joint assessment and examination K Hashemi

10.00am Interpretation of musculoskeletal x-rays C Blakeley

10.40 Coffee

11.00am The painful shoulder C Blakeley

11.30am The painful hand K Hashemi

12.00pm The painful knee C Blakeley

12.30pm Principles of management of fractures S Bannergee

and dislocations

1.00pm Lunch

2.00pm MSK Scenario 1 C Blakeley

2.15pm MSK Scenario 2 C Blakeley

2.30pm Reduction techniques and M Agrawal

plaster application – upper limb

3.20pm Reduction techniques and C Blakeley

plaster application – lower limb

4.10pm Close of day

The Injured Knee
 Background
Very common problem in A&E
A thorough assessment needs to be done
to exclude significant injury
Method:
- History
- Examination
- Investigation – x-ray, bloods, CT, US
 History
Several mechanisms exist:
- twisting injury with fixed foot (football)
- direct blow to anterior knee
- direct blow to lateral knee (O’Donoghue’s
triad)
- sudden block to extension (rugby)
 History
Did patient or anyone else hear a “pop”?
- diagnosis?
Did the knee swell? How quickly?
Could the patient play on?
Where is the pain?
Any locking, giving way etc? (esp delayed
presentation)
Previous knee problems/surgery?
 Examination - Look
Can the patient walk, is there a limp?
Is the skin intact?
Is there an effusion
Is there any obvious deformity?
Any quads wasting?
 Examination - Feel
Is it hot?
Where is it tender? – a systematic
approach to palpation needed
Is there an effusion?
Any palpable deformity – eg quads
rupture?
 Examination - Move
Is the extensor mechanism intact?
Active/passive ROM
- Is there “true” locking?
Resisted – assess quads strength
Any abnormal movement suggesting rupture of
cruciates or collateral?
- Valgus/varus stressing, anterior draw and
Lachman’s
 Examination - technique
YouTube - Knee Examination
Examination – McMurray’s test
YouTube - McMurrays test
 Examination – Pivot shift
YouTube - Knee Exam (22 of 27): Pivot sh
ift
 Investigations – X-rays
AP
Lateral
Skyline view – for patella dislocation (post
reduction)
Intercondylar views for loose bodies
Stress views for rupture of collaterals
 Investigations
CT scan – 3D reconstruction for tibial
plateau fractures
US for patellar tendon/quads tendon
ruptures
MRI – subtle bone injury, cruciate,
collateral and meniscal injury
 Fractures - patella
Direct blow
Block to extension
Disruption of extensor
mechanism
Usually displaced –
need tension band
wiring
If undisplaced –
cylinder cast
 Dislocations
Patellar dislocation – common
- Dislocates laterally
- Under Entonox apply pressure to outer
border of kneecap and extend knee.
- Place in cylinder cast 6/52 if first time
Knee – rare. Severe injury, injury to many
structures in knee. Risk to Popliteal artery
therefore requires prompt reduction
 Significant soft tissue injury
Tendon ruptures – Quads and patellar
Meniscal injury
Collateral ligament rupture
 The extensor mechanism
The extensor
mechanism may be
disrupted in 3 places
Where, depends on
age.
Patient unable to SLR
Clinical examination
and x-ray will tell you
where
 Quads rupture
Palpable dip at quads
insertion to patella
Patella baja
Refer – needs
operative repair
 Patella tendon rupture
Painful defect over patellar tendon.
Unable to SLR
Patella alta
If any doubt US
Refer for surgical repair
Patella tendon rupture
Significant soft tissue injury –
Cruciate injuries
Common injury (ACL > PCL by far)
Sports injury, twisting mechanism
“Pop” felt with rapid accumulation of
effusion
Signs of ACL rupture may de difficult to
detect due to pain/spasm
Xray – effusion, if lipohaemarthrosis ?
avulsion #
Refer to # clinic as most need arthroscopy
 Cruciate avulsion fractures
ACL avulsion PCL avulsion
 Meniscal tears
Common injury
Sports related
Effusion present – haemarthrosis if
peripheral tear/detachment
Give episodes of:
- Recurrent pain
- Locking
- Giving way
 Meniscal tears
Effusion
Joint line tenderness
+ve McMurray’s
+ Apley’s compression
 Meniscal tear
X-ray to rule out #
If “locked” needs
admission – use
Entonox to determine
if locked
Otherwise # clinic for:
- MRI
- Arthroscopy
Rupture of Collateral ligament
From severe blow to outer or, less
frequently, inner aspect of knee.
MCL > LCL
If ruptured may not get tense effusion
If very painful may not be able to stress
the ligament.
Infiltrate lignocaine and repeat +/- stress
views
Rupture of Collateral ligament

Stress views
Opening up of medial
joint space suggests
MCL rupture
If ruptured – place in
cylinder cast
# Clinic - ?for
operative repair
Any questions?
 Interpretation of
musculoskeletal -xrays
 Appearance of fractures
Depends on:
- Separation of fracture fragments
- Impaction of fracture fragments
- Angle of beam in relation to fracture gap
 Separation of fragments
Results in a lucent
line
Typical appearance
But xrays must be
travelling in same
plane as #
 Impaction of fragments
Fragments driven into
each other forms a
zone of sclerosis
May be difficult to see
Common pitfall –
impacted subcapital #
NOF
 How many views?
At least two views are
needed at right
angles
May be more
Should involve “joint
above and joint
below” – with
exceptions of wrist
and ankle
 Normal anatomy
Must know normal anatomy
Growth plates in children
Accessory ossicles
Nutrient vessels
Growth plates
 Accessory ossicles

Os naviculare Os trigonum
Nutrient vessels
 How to describe an xray?
“The x-rays show a
transverse fracture of
the distal radius with
no displacement but
30 degrees of dorsal
angulation. There is
no extension into the
joint”
 Areas to be covered
Shoulder girdle
Elbow
Wrist and hand
Hip and pelvis
Knee
Ankle and foot
Fracture healing on xray
Miscellaneous - infection
Sterno-clavicular joint
Dislocated SC joint
 Acromio-clavicular joint
Need stress or
weight-bearing views
Look for step in joint
Depending on degree
of step could be:
- Subluxation
- Dislocation
 Gleno-humeral joint
The views
required are a
standard AP and
a “lateral”, either
axillary or trans-
scapular view.
Additional views
essential to
exclude
dislocation
Axillary and Trans-scapular views
 Paediatric shoulder

Epiphyseal lines may be confused as a fracture

Epihyses also visible on acromion and coracoid
Anterior dislocation
 Posterior dislocation
AP – look for
“lightbulb” sign.
If positive suggests a
posterior dislocation
Lateral view needed
to confirm
Axillary view of posterior dislocation
 Elbow
Presence of fat pad
indicates a joint
effusion
Raised fat pad
anteriorly
Visible fat pad
posteriorly
If # not immediately
obvious look carefully
at radial head.
 Paediatric elbow

Difficult to interpret – need knowledge of anatomy

Remember CRITOL rule
Forearm fractures
 Wrist
Standard view is AP and lateral
Note any obvious fracture
Look at alignment of
radius/lunate/capitate/ 3rd metacarpal
Look for increased intercapal gap
suggesting significant ligamentous injury
Normal wrist
Normal wrist
Dislocation
Ligamentous injury
LOWER LIMB XRAYS
Hip – Impacted subcapital fractures
Look closely for:
- Break in cortex
- Sclerotic line across
neck
- Angulation of
trabecular lines

If in doubt, admit for

MRI
Left hip pain
5 months later
 Hip - SUFE

Important diagnosis in limping child, need frog lateral

views. Remember gonadal cover.
 Knee - lipohaemarthrosis
Lipohaemarthrosis is
seen as fluid level
Indicates intra-
articular fracture
Knee – tibial plateau fracture

Draw vertical line down from femoral epicondyle

Look for lucent line
 Ankle - Mortise
Knowledge of anatomy
important
Look for:
- Fracture
- Talar shift – think about
high fibular # if no #
visible
- Diastasis

Consider stress views if

significant ligament injury
is suspected
Ankle – Talar shift and diastasis
Ankle – stress views (talar tilt)
Ankle - children
Ankle – Undisplaced SH 1 # lat
malleolus
 Foot - alignment
2nd metatarsal – medial edge of middle cuneiform
3rd metatarsal – medial edge of lateral cuneiform
Foot – Lis Franc
Foot – stress fractures
Fracture healing on xray
Any questions?
The painful shoulder
 Anatomy
Complex joint
3 joints comprise shoulder girdle
- Gleno-humeral – wide ROM
- AC joint- allows scapulo-thoracic
movement
- SC joint – as above
SC joint
AC joint
Gleno-humeral joint
 Pathology
Acute Chronic
Fractures Arthritis
Dislocations Rotator cuff tears
Rotator cuff tears Tendonitis
Acute calcific Bursitis
tendonitis
Septic arthritis Other pathology
Bony mets
Neck/chest - referred
 Symptoms
Pain
Deformity eg AC joint subluxation
Decreased ROM
- May be due to pain
- May be due to rotator cuff tear
- May be adhesive capsulitis
 Signs
Look, feel, move
Active, passive, resisted
Special tests - apprehension test,
instability and impingement tests
Distal neurovascular status
 Examination - technique
YouTube - Shoulder Examination
 Investigations
X-rays – Shoulder, AC joint, clavicle
CT – complex fractures, dislocation of SC
joint
Ultrasound – Soft tissue problems such as
bursitis, tendonitis, tears
MRI – Soft tissue injury plus bony
pathology
Bloods – only if relevant to presenting
problem
 Fractures and dislocations
SC joint dislocation
Clavicle fracture
AC joint dislocation
Dislocated shoulder
Proximal humeral fractures
SC joint dislocation - Anterior
SC joint dislocation - Posterior
Mechanism either indirect
or direct blow to medial
clavicle
Immediate threat to
airway, lungs and great
vessels
Difficulty swallowing
Refer for closed reduction
If suspected clinically
organise CT – confirms
diagnosis also detects
complications
 Fractured Clavicle
Common injury
Ignore wide
separation of
fragments
Occasionally injury to
major vessel or pleura
Tx Broad arm sling
not C&C
AC Joint dislocation
 Fractures - NOH
Neck of humerus
Common
Conservative
management largely
Look for pathological
fracture as common
site for bony mets
Fractures – Comminuted # humeral
head
May need referral for
hemiarthroplasty
Fractures – Greater tuberosity
Common
Often seen as part of
dislocation
Patient unable to
abduct
Unless significantly
displaced,
conservative
management
 Shoulder dislocation
Anterior – common
Posterior – rare
Inferior or Luxatio Erecta – very rare
Shoulder dislocation - Posterior

Causes – seizure, electric shock or direct blow to

anterior shoulder
About 70% missed without lateral radiograph
Shoulder dislocation – Luxatio
Erecta
Reduction of Luxatio
 Painful “arc”
Syndrome of pain in the shoulder and
upper arm in the mid-range of abduction
Painfree at the extremes
Caused by:
- Supraspinatus tendonitis +/- calcification
- Subacromial bursitis
- Partial tear of supraspinatus
- Undisplaced fracture of greater tuberosity
Acute calcific tendonitis
Undisplaced fracture of greater
tuberosity
 Painful arc
Difficult to distinguish these
clinically
Need xray to exclude # and
US/MRI to look at soft
tissues
Tx
- Rest and NSAIDs
- Steroid injection
- Decompression
 Frozen shoulder
Pathology ill understood – adhesive
capsulitis
Patient complains of pain and uniform loss
of gleno-humeral movement
Often precipitating injury - #, rotator cuff
tear
No evidence of joint destruction
Frozen shoulder
 Frozen shoulder
Symptoms gradual in onset and recover
over a period of months
Tx – rest, NSAIDs, steroids, MUA
Any questions?
Reduction techniques in
the lower limb
Dislocated hip - anterior
 Dislocated hip - anterior
Anterior rare
Forced abduction eg RTA
with knee hitting
dashboard
Reduction
Sedation
GA with muscle relaxant
Stabilise pelvis
Strong traction and
internal rotation of hip
 Dislocated hip - posterior
Common injury
Esp post THR
Injury to sciatic nerve
– document
Sedation and IV
opiates
Reduction technique
 Technique
Adequate sedation and analgesia
First person stabilise pelvis
Second person flex hip/ knee to 90
degrees
Apply traction with counter traction with hip
laterally rotated
Once reduced place abduction pillow
between legs
 Hip reduction - technique
YouTube - Hip Dislocation Reduction
 Shaft of femur
Displacement
increases pain and
blood loss
Give adequate IV
analgesia, sedation
not necessary
Reduce with splint
Eg Thomas or
Donway traction splint
 Dislocated patella
Common problem
Clinically obvious
Reduce under
Entonox
No x-ray required
beforehand
Technique
Xray after – plus
skyline view
Cylinder cast
Skyline view of patella
Reduction of dislocated patella -
technique
YouTube - Reducing the Dislocated Patell
a
Dislocated knee
 Dislocated knee
Rare injury
Direct blow prox tibia – eg RTA
Injury to popliteal vessels
Prompt reduction under
sedation/analgesia
Longitudinal traction usually suffice
Assess stability of knee
Place in backslab
 Fracture/dislocation of ankle
Not uncommon injury
May compromise the
vascular supply
Prompt reduction
under sedation and IV
analgesia
Technique
Realign foot
Backslab
All will require ORIF
Reduction of dislocated ankle -
technique
YouTube - Reduction of Lateral Ankle Disl
ocations