Unit:

Musculoskeletal III (Pelvis and Lower Extremity)

Content:

Pelvis, hip, femur, knee, fibula/tibia, ankle, foot

Goal:

For each of the above structures, the student will • Develop and demonstrate thorough didactic knowledge of normal function • Develop and demonstrate thorough clinical skills in evaluating normal function • Develop and demonstrate thorough didactic knowledge in evaluating and managing common disorders • Develop and demonstrate thorough clinical skills in evaluating and managing common disorders

Anatomy:

For each of the above structures the student will be able to identify, on models and patients, the normal arrangement and function of • Bones • Ligaments • Tendons • Cartilage • Muscles of movement • Artery/vein supply • Nerve supply

Physiology:

For the above tissues the student will know • Normal physiology in children and adults • Physiology of healing

Pathology:

For the following disorders the student will know physical findings, risks and causes, useful x-ray, imaging and diagnostic studies, urgencies/emergencies, management, and referral • •

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4/05

Lumbar-sacral plexus disorders 1. Low back pain (review form 1st Quarter) 2. Disc disease (review from 1st Quarter) Pelvis disorder 1. Sprain of SI joint 2. Separation of pubic symphysis 3. Pelvic fracture 4. Pelvic bone metastases (pain syndrome) Hip disorders 1. Fractures o Subcapital, tanscervical, intertrochanteric, subtrochanteric, issue of aseptic necrosis 2. Hip dislocations (anterior, posterior) 3. Bursitis 4. DJD

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Unit:

Musculoskeletal III (Pelvis and Lower Extremity)

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4/05

5. “Pulled muscle”: groin injury, hamstring injury 6. Septic hip joint/osteomyelitis 7. Bone metastases (pain syndrome) Knee disorders 1. Fractures o Distal femur o Patella o Proximal tibia o Epiphyseal fracture 2. Ligament sprains, tears o Lateral collateral o Medial collateral o Anterior cruciate o Posterior cruciate 3. Tendon problems o Sprain, tear of quadriceps and patella tendons o Tendinitis of quadriceps and patella tendons o Osgood Schlatter Disease (covered more in Peds II) 4. Meniscus tears (medial, lateral) 5. Bursitis o Prepatellar o Infrapatellar o Anserine o “Baker’s cyst” 6. Septic knee joint, osteomyelitis 7. Bone metastases (pain syndrome) 8. DJD of the knee 9. Patellofemoral Pain Syndrome o Q angle & Patella tracking problems o Dislocation o Chondromalacia Lower Leg disorders 1. Long bone fractures: tibia, fibula 2. Compartment syndrome 3. Shin splints Ankle disorders 1. Achilles tendinitis, tendon rupture 2. Posterior tibialis tendinitis, tendon rupture 3. Ankle fractures 4. DJD 5. Ankle sprain o Medial deltoid ligament (rare) o Lateral “Y” ligaments (common) 6. Achilles tendonitis 7. Achilles tear, rupture 8. Ankle joint infection, osteomyelitis

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Unit:

Musculoskeletal III (Pelvis and Lower Extremity) •

Foot disorders 1. Hallux valgus (bunion) 2. Heel fracture 3. Plantar fasciitis 4. Morton neuroma 5. Foot bone fractures 6. Hammer toe 7. Corns, calluses 8. Ingrown toenail (treatment to be discussed in Surgery Unit: Office Procedures)

Diagnoistic Testing Students will know when to order and demonstrate basic interpretation of results of Orthopedic X-rays CT scan MRI Arthrogram Arthroscopy Bone scan (for healing fractures, metastases, osteomyelitis) CBC and ESR Synovial fluid analysis Nerve Conduction Velocity studies Electromyography Clinical Skills :

Students will be able to demonstrate the following History Taking and Physical Exam skills History Taking Skills • • • •

Know the Review of Systems for musculoskeletal and neurologic systems (review of 1st Quarter material) Be able to take a focused history on a patient presenting with painful pelvis, hip, knee, ankle, foot Be able to take a focused history on a patient presenting with muscle weakness of lower extremity Be able to take a focused history on a patient presenting with parethesias/dysaesthesias of lower extremity Physical Exam Skills

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Demonstrate physical exam skills as outlined in the Clinical Skills Manual 2004-2005 covering 1. MSK and Neurologic screening exam of normal lower back, pelvis, hip, knee, ankle, foot (review of 1st Quarter material)

4/05

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Unit:

Musculoskeletal III (Pelvis and Lower Extremity)

2. Special MSK and Neurologic maneuvers/techniques to evaluate the following: § § §

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4/05

Low back pain and spinal nerve root compression syndromes (review of 1st Quarter material) Pelvic pain (review of 1st Quarter material) • SI joint pain Hip pain • Differential diagnosis: DJD, bursitis, dislocation, fracture, joint infection, osteomyelitis, metastases, referred pain • Special exams: o Trendelenberg test o Leg length o Pelvic rock test—SI joint instability Knee Pain, locking, instability • Differential Diagnosis: DJD, rheumatoid arthritis, chondromalacia, bursitis, ligament damage, meniscus damage, fracture, joint infection, osteomyelitis, gout, metastatses, referred pain o Valgus stress o Varus stress o Lachman’s test o Anterior drawer sign o Posterior drawer sign o Squat and “duck walk” o Apprehension test o McMurray’s test o Apley’s test o Ballotment of patella o Bulge sign Ankle and Foot Pain and Dysfunction • Differential Diagnosis: DJD, rheumatoid arthritis, bursitis, tendinitis, plantar fasciitis, ligament damage (sprain), meniscus damage, fracture, joint infection, osteomyelitis, gout, bone metastases • Special exams o Anterior drawer o Thompson’s test o Achilles bursitis o Metatarsalgia o Test for peroneus brevis & longus o Grading sprain: I, II, III

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Unit:

Musculoskeletal III (Pelvis and Lower Extremity)

3. Musculoskeletal and Neurologic maneuvers and techniques (including inspection, palpation, ROM, DTRs, strength testing) to evaluate muscle weakness and atrophy of lower extremity 4. Musculoskeletal and Neurologic maneuvers and techniques to evaluate paresthesias of lower extremity NOTE:

When evaluating musculoskeletal complaints, always compare affected side with unaffected side; examine the joint/structures above and below the affected area. In some cases a pelvic exam is warranted.

Treatment:

The student will be able to • Demonstrate understanding of indications for and techniques of joint aspiration and joint/trigger point/ganglion injection • Demonstrate competence in applying splints, casts, traction, knee immobilizers, crutches, cane • Know appropriate referral to physical therapy • Demonstrate competence in prescribing (see Pharm Curriculum) 1. Acetaminophen (Tylenol) 2. NSAIDs : Aspirin, ibuprofen (Motrin), naproxen (Narporsyn, Aleve), indomethicin (Indocin), meloxicam (Mobic), ketrolac (Toradol), COX-2 celecoxib (Celebrex) 3. Muscle relaxants : Cyclobenzaprine (Flexeril), methocarbamol (Robaxin), carisprodol (Soma) diazepam (Valium), chlorzoxazone (Parafon Forte DSC), orphenadrine (Norflex) 4. Analgesics (narcotic): Codeine, hydrocodone, morphine, propoxyphene (Darvocet-N), combinations such as vicodin 5. Pain control: non- narcotic, tramadol (Ultram) 6. Joint compounds/supplements: glucosamine, chondroitin 7. Antibiotics 8. RICE •

Patient Ed:

4/05

State the indication for surgical intervention 1. Compartment syndrome 2. Arthroscopy for meniscus & ligament repair 3. Ruptured tendon repair 4. Reduction of dislocations 5. ORIF vs. Closed reduction of fractures 6. Joint replacement 7. Lumbar spine fusion for disc disease (review from 1st Quarter) 8. Joint or bone infection (osteomyelitis) The student will be able to provide patient education on the following topics

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Unit:

Musculoskeletal III (Pelvis and Lower Extremity) • • • • • • •

Charting:

Injury prevention Importance of managing co- morbid conditions Expected normal recovery to pre- injury state Self-care for rehabilitation at home (RICE, exercise) Proper care and use of cast, splints, cane, crutches, traction Proper use of medications Warning signs of worsening condition

Student will be able to organize and write a SOAP note for any of the disorders listed for pelvis, hip, knee, leg, ankle, foot

Textbooks: Tortora, et al 10th edition Much of this should be review of earlier competency; specific questions will be focused on diagnosing the disorders listed above

Bates’ 8th edition Clinical Skills Manual 2004-2005 Hoppenfield Rothenberg (X-rays) Current ER Dx & Tx 5th edition (Stone)

Current Medical Dx & Tx 2004 BBZ 6th edition Fischbach (Laboratory & Dx tests)

4/05

Review Chapter 6 Chapter 7 (lower back, sacrum, coccyx), Chapter 8 (pelvic bones, lower limb), Chapter 9 (movements of synovial joints: emphasis on hip, knee, ankle Chapter 10 (skeletal muscle tissue through exercise induced muscle damage, plus regeneration of muscle tissue, aging and muscle tissue Chapter 11 (how muscles produce movement, muscles of hip, muscles that move the femur (hip), knee, foot and toes) Chapter 13 (lumbo-sacral plexus with attention to femoral and sciatic nerves, dermatomes) Chapter 21 (arterial and venous supply of pelvis and lower limb) Review MSK and neuro exam of lower back, hip, knee, ankle, foot Review MSK and neuro of lower back, hip, knee, ankle, foot Review MSK and neuro exam of lower back, hip, knee, ankle, foot Bones Chapter 28 pelvic gridle injuries, hip fractures, dislocation, lower extremity injuries Pg 788-791, 795-797 825-827, Chapter 68, 71 (review), 72, 73 Where appropriate for analysis of disorders

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