1. Assess airway - CXR immediately

2. Stabilize cervical vertebrae

3. Assess breathing w/ ABG's

4. Assess circulation

5. Survey head, cervical spine, chest, abdomen, pelvis, extremity exam

1. Open fractures

2. dislocated hips or spine

3. compartment syndrome

4. cauda equine syndrome

5. extremities w/ neurological or vascular compromise

1. location in bone -distal, middle, proximal thirds

2. open**(compound) or closed

3. pattern- transverse, oblique, spiral, comminuted

4. displacement - minimal, partial, full

5. angulation - varus or valgus 

Inward angulation of distal segment of bone or joint 

"Bow-legged"

Outward angulation of the distal segment of a bone or joint.

"Knock-kneed"

-many etiologies (fractures**, trauma, burns)

-elevated pressure within a closed fascial space

-reduced tissue perfusion resulting in ischemia and necrosis

**Grade III open fracture, most common cause

-pain out of proportion & on passive motion

-palpably tense compartment

Later symptoms:

-paresthesia, hypoesthesia

-paralysis

-pulselessness/pallor 

1. Low back pain

2. Knee injury/pain

3. Shoulder

4. Foot and ankle

5. Carpel tunnel 

-can be caused by falling on an outstretched hand

-often occurs in younger people

-can be missed on x-ray 

-bone may not be swollen due to low blood supply

-even if x-ray is unremarkable, is snuffbox is tender, treat as if fracture 

-fracture of the distal radius

-usually elderly due to fall

-causes distal fragment to displace dorsally with dorsal angulation

-carpal tunnel syndrome can accompany if medial nerve is disrupted

Tx: elderly - percutaneous pins; young pt - set with locking anatomical plates to push wrist back

-short oblique or transverse fracture of the radius with associated dislocation of the distal ulna

-adults need surgery and plating for management 

Intertrochanteric/subtrochanteric 

Femoral head fracture 

Young pt: can be reduced and pinned

Elderly: femoral head removed, hemiarthroplasty 

-most common ankle fracture

-caused by external rotation of the foot

-boot (6 weeks) for management

-foot fracture of calcaneous (heel) bone

-caused by landing on heel

-appears like eggshells 

-presents w/ very swollen foot

-bleeds a lot 

Need to identify whether the pain is from visceral causes, nerve damage, or intrinsic shoulder problems 

-take good history (radiation, intensity, ROM, mechanism of injury)

-surface anatomy for asymmetry, atrophy, lesions

-supraspinatous and infraspinatous for atrophy

-scapular winging or muscle fasciculations 

-AP view of glenohumeral joint, possible MRI

-results from repetitive overuse, acute strain, overhead sports

-presents w/ greater tuberosity tenderness

-full range of motion and good strength

-positive impingement sign (internal rotation of shoulder)

**Supraspinatous most often involved

-can be from trauma, direct fall, dislocation, degenerative

-presents w/ pain and weakness in deltoid area or pos. deltoid

-positive impingement sign 

-active motion limited by weakness

-passive motion usually preserved

-weakness of external rotation against resistance

-positive "Drop-arm" test in massive tears**

-direct palpation on PE will cause pain

-swollen compared to other shoulder

-crossing arm in front of body will cause pain

-pain is localized to proximal humerus and shoulder joint with resisted supination of forearm aggravating pain

-pain may occur on manual flexing of elbows and palpation of tendon itself

**Yergason test used to detect instability  

-inflammation of subacromial bursa 

-shows mildest signs of pain/impingement

-active ROM is limited by pain

-positive Neer's impingement (internally rotated shoulder is moved into forward flexion) 

-loss of articular surface

-in severe cases, needs treatment with shoulder replacement

-more common in hip

"Frozen shoulder"

-often spontaneous, but can follow trauma, tendonitis

-loss of passive and active ROM

-Tx: NSAIDS, injections, PT 

-most common type

-occurs when falling on an outstretched arm; humeral head forced into glenoid cavity 

-shoulder is extended, abducted, and externally rotated 

-on PE: humeral head prominence is lost, step-off anterior to acromion, + apprehension test

-results in recurrent instability in younger patients and older patients can have as associated acute rotator cuff tear 

-only small amount of cases but often missed

-PE: pt. won't be able to externally rotate arm to neutral (mechanism is that the arm is internally rotated and humeral articular surface gets stuck behind glenoid cavity)

-can happen in falls and seizures

-X-ray: Ice cream cone sign 

-elbow fracture

-results from a fall on outstretched hand

-tender over radial head

-pain w/ attempted rotation including supination and pronation

-results from fall directly on elbow 

-olecranon is very swollen 

-palpable gap 

-loss of movement 

-common in 10-20 year olds

-most are posterior

-most due to hyperextension of joint or a valgus force (force from outside to in)

-PE: swollen and deformed 

-check neurovascular supply here as well

-usually from trauma, infection, inflammation

-appears as "egg sac" of fluid

-aspirate and look at fluid

-infections may help with inflammation or infections 

-"tennis elbow"

-more common in non-athletes than tennis players

-caused by strain or overuse

-PE: tender and may be swollen; pain with grip or resisted wrist dorsiflexion 

-most common compressive neuropathy of UE

-effects median nerve of wrist 

-females > males, ages 40-60

-results from trauma, occupational, DM, RA, thyroid disease, pregnancy, fracture

-paresthesias in distribution of median nerve

-pain in fingers, wrist, forearm

-weakness and clumsiness

-night pain

+ Phalen's test, + Tinel's test

-loss of sensation

-thenar atrophy 

-rest

-activity modification

-splinting at work, at night

-steroid injection

-surgery 

-mechanism of injury

-locking/clicking/catching

-ability to bear weight

-ability to continue with activities

-swelling, onset of swelling

-palpation, ROM, effusion, strength, special tests

-most commonly caused by non-contact twisting

-also caused by hyperextension, direct blow

Sx: hear a pop, swelling develops over hours, may have effusion

-instability w/ lateral movement 

Dx: anterior drawer tests, pivot twist test, Lachman's test

*Segung fracture is pathognomonic for ACL tear

-caused by hyperextension of knee, or direct blow

-could fall onto flexed knee with plantar flexed foot

Dx: posterior drawer test, posterior sag test, dial test, quadriceps action test

-valgus force to the knee (direct blow from outside)

-Grade 1: microscopic tear; pain but no laxity

-Grade 2: attenuation; detectable laxity & tenderness

-Grade 3: frank rupture; joint is grossly unstable

Dx: Valgus stress testing at 30 degree flexion and in full extension

-degenerative causes, more commonly medial meniscus; arthritic older people; acute usually medial

-lateral meniscus, commonly assoc. with ACL tears

-assoc. with rapid loading and twisting movements 

-swelling comes over several days

Sx: clicking, effusion

Dx: McMurray's test (make the pop come about)

-strain at calcaneal insertion 

-associated with heel pain

-"heel spur" can be seen on X-ray

-caused by running, repetitive strain, overweight 

-have pt. get orthotics, stretch, NSAIDS

-takes several months to heal

-pain associated w/ overuse in the ball of foot

-especially occurs in people w/ high arches

-point tenderness

-usually in 2nd or 3rd metatarsal 

-X-rays commonly negative, but can rule out neuroma

-later x-ray may show small line or callus (boney growth)

-diffuse tenderness @ attachment of anterior tibialis tender to tibia, causes anterior pain

-can also occur posteriorly 

-restrict running

-NSAIDS, orthotics 

-occurs at insertion

-need surgery to remove osteophytes 

-stretches, NSAIDS, heel lifts can help

-takes a long time to recover

-pt. will hear pop or snap

-commonly no hx. of achilles problems

-occurs with acute plantar flexion in older individuals

-Dx: Thompson test; normally, calf squeeze would plantar flex foot, if ruptured, no movement occurs

-usually occurs on lateral side as a result of inversion injury

-Dx: AP, lateral and mortise X-rays

**Don't miss serious fractures that present the same way

-RICE

-aircast and rehab 

-will cause pain between the metatarsals

-X-ray will help rule this out 

-Tx: orthotics, pads, cushions 

-idiopathic juvenile avascular necrosis of femoral head

-most common: boys ages 4-8 (whites & smoking in home)

-painless limp followed by loss of motion

-episodic (periods of normalcy in between limps)

-PE: asymmetric rotation, flexion contracture, waddling gait

-most resolve spontaneously w/in 1-2 years 

Dx: X-ray

-infection of joint space

-usually monoarticular 

-characterized as gonococcal or non-gonococcal 

-usually bacterial

-presents as painful, swollen joint, +/- fever, poor ROM

-may accompany osteoarthritis 

-urgent action needed with parenteral antibiotics, surgical drainage and/or aspiration 

-primary, lateral curvature of the spine

-genetic

-usually not assoc. with pain

-treatment depends on curve, skeletal maturity, risk of progression

-bracing needed is child is still growing

-surgery if severe enough curve

-1 in 100 babies born with this

-characterized by asymmetric knee heights, abduction, and buttock creases 

-Dx: Barlow maneuver makes hip pop out; Ortolani makes it pop back in 

-causes lots of pain early in life; child can't walk or run

-if caught early, child can wear a harness to correct problem

-infection of bone; progressive, inflammatory

-most often in metaphysis of long bones 

-usually result of bacteria spread from blood to bone

-acute: local pain, redness, toxemia, fever

-chronic: indolent, less specific

-Dx: X-ray; biopsy to determine causative agent 

Tx: prolonged antibiotic use; surgery for chronic 

-failure to close of upper femoral epiphysis allowing displacement of femoral head on neck

-onset may be acute or chronic

-may have referred knee pain

-african american children* and overweight children

-surgical emergency

-toes point out