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MSK > Lecture 2: MSK Injuries > Flashcards

Lecture 2: MSK Injuries Flashcards

1
Q

What is a muscle strain?

A
  • injury of muscle or muscle-tendon, usually distally
  • MC in muscles with 2 joints
  • MOA: Forceful eccentric loading

Eccentric = lengthening muscle while under load. (lowering coffee cup to a desk = eccentric loading of bicep)

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2
Q

What is a ligament sprain, MC locations, and MOI? (4)

A
  • Trauma to ligaments that connect bones
  • MC: ankle, knee, wrist
  • MOI: Overextension of joint
  • NOT COMMON IN CHILDREN OR OLDER ADULTS

Ligaments Link

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3
Q

How do strains/sprains usually present at time of injury?

A
  1. Popping, snapping, tearing sensation
  2. Pain, swelling, stiffness, difficulty bearing weight
  3. 24h-48h later: bruising/discoloration
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4
Q

Assessing what helps us determine the structures involved in a strain/sprain?

A
  • SYMMETRY!! will see asymmetric swelling, tenderness and ecchymosis of injured area
  • also point of maximal tenderness
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5
Q

How does a muscle strain present on PE?

A
  • Visible/palpable defect maybe visible
  • Pain with active and passive flexion
  • If no contraction, complete rupture.
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6
Q

How does a ligament sprain present on PE?

A
  • Pain with active and passive ROM
  • Joint instability/laxity, esp in grade 3
  • Special tests can be used, i.e. anterior drawer
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7
Q

How are muscle strains graded? (4)

A
  1. Grade 1: Tear of a few fibers < 10%, fascia intact
  2. Grade 2: Tear of more fibers < 50%, fascia intact
  3. Grade 3: Tear of most or all fibers, fascia intact
  4. Grade 4: Full tear, fascia disrupted

10, 50, 100, 100 + Fascia

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8
Q

How do you grade ligament sprains?

A
  1. Grade 1: Mild, few fibers torn, no instability.
  2. Grade 2: Moderate, partial tear, some laxity
  3. Grade 3: Severe, complete ligament tear, laxity
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9
Q

When is XR used for strain/sprain evaluation? (4)

A
  • High concern for possible fracture
  • Positive Ottawa ankle rules
  • Worsening pain/swelling with appropriate management
  • Persistent pain/swelling after 7-10d of appropriate management
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10
Q

What are the ottawa ankle rules for ankle sprains? (3)

A
  • Pain at medial malleolus or along distal 6cm of posterior/medial tibia
  • Pain at lateral malleolus or along distal 6cm of posterior fibula
  • Inability to bear weight immediately and for four consecutive steps in the ED
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11
Q

What are the ottawa ankle rules for foot sprains? (3)

A
  • Pain in midfoot + base of 5th metatarsal (pinky)
  • Pain in midfoot + navicular bone
  • Inability to bear weight immediately and for four consecutive steps in the ED
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12
Q

When is MRI utilized for strains/sprains?

A
  • Confirming grade
  • Indicated if suspected rupture or severe sprain
  • Indicated if surgery is likely
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13
Q

What are the 4 phases of healing?

A
  1. Hemostasis
  2. Inflammatory
  3. Proliferative
  4. Maturation
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14
Q

What occurs on the skin during hemostasis in a strain/sprain? (1)
Management during this phase? (2)

A
  • Platelets aggregate & release cytokines, chemokines, hormones. Vasoconstriction occurs to limit bleeding. This causes temporary skin blanching
  • TX: Protection/compression of injured area
  • Treat pain and swelling with ice

Immediately after injury

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15
Q

How does the inflammatory phase present for a strain/sprain? (2)
Management? (2)

A
  • 0-72h post injury
  • bleeding/necrosisinduces inflammatory cascade. swelling occurs. capillaries dilate and become more permeable which releases blood into the extravascular space (bruising).
  • Protect/compress area
  • Control pain and swelling via ice
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16
Q

How does the proliferative phase present in sprains/strains? (3)
Management? (2)

A
  • 72h-3wks
  • granulation tissue formed and Collagen deposition occurs. Neovascularization occurs at injury and inflamm mediators reduce
  • Continue to protect area with pain and swelling control
  • Full Assisted ROMs
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17
Q

How does the maturation phase present in strains/sprains? (2) Management? (2)

A
  • 3wks - 2 years
  • Collagen and myofibers increase in number/strength/organization
  • Maintain ROM and flexibility
  • Increase strength/endurance/power/speed/agility
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18
Q

What is PRICE?

A
  1. Protection (Padding, slings, braces, ACE, etc)
  2. Rest (Avoid weight bearing)
  3. Ice (ASAP, also avoid heat))
  4. Compression (ACE)
  5. Elevation (above heart)

Ice 15-20 minutes q2-3h for 48h. Avoid heat for 2-3d.

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19
Q

When is Ice contraindicated in strain/sprain management?

A
  • Raynauds
  • PVD
  • Impaired sensation
  • Cold allergy/HSR
  • Severe cold induced urticaria
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20
Q

When is surgical repair indicated for strain/sprain?

A
  • Complete tear
  • Refer if unstable joint or failed therapy or neurovascular compromise
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21
Q

First line therapy for pain management in strains/sprains?

A

NSAIDs

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22
Q

What are the extrinsic and intrinsic factors for overuse syndrome?

A
  • Extrinsic: Repetitive mechnical load or equipment problems
  • Intrinsic: Anatomic weakness/imbalance, age, systemic
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23
Q

What medication class is known for tendinopathy?

A

Quinolones

Tendon rupture

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24
Q

How does overuse syndrome present? (3)

A
  • Pain, fatigue, numbess, swelling
  • Callous formation at tendinous insertion
  • Exacerbated by stretching or contracting
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25
Q

When would radiograph be used for overuse syndrome?

A
  • R/o fx
  • Calfication or spur formation of tendon at insertion site
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26
Q

Management of overuse syndrome

A
  • Resolves spontaneously if mild
  • Avoid activity that led to it in the first place
  • Pain management: ice/heat, NSAIDs, corticosteroid injections (ortho)
  • PT/OT
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27
Q

What is the periosteum?

A
  • Thick outer layer
  • Containing vessels, nerve endings, repair cells

Pain comes from here. Painful periosteum

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28
Q

What is the endosteum?

A

Inner lining of marrow cavity

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29
Q

Which bone location is most susceptible to infection/fx?

A

Epiphysis, which has the growth plate and is found at the end of a bone in children

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30
Q

Which bone location is most susceptible to compression factures?

A

Metaphysis

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31
Q

What part of the bone is the main structural support?

A

Diaphysis

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32
Q

Define a fracture.

A

Disruption in continuity or structural integrity of a bone.

Hairline = fracture

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33
Q

What bones are most susceptible to fx?

A

Extremities

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34
Q

When is CT/MRI indicated for fx?

A
  • Need to confirm Fx
  • Further define complex fx prior to surgical repair
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35
Q

4 components of describing a fx

A
  • Open vs closed
  • Location
  • Orientation/direction
  • Displacement
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36
Q

How do you classify open vs closed fx?

A
  • Grade 1: low energy with open wound < 1cm and no contamination
  • Grade 2: moderate, comminution, 1-10cm wound with some contamination
  • Grade 3A: high energy, > 10cm, gross contamination
  • Grade 3B: 3A + exposed bone
  • Grade 3C: 3B + vascular involvement

Gustilo and Anderson Classification

Assess need for ID and ortho
3B = see Bone

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37
Q

Describe this fracture location

A

Mid-shaft diaphyseal fx of the right tibia

Child

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38
Q

Describe this fracture location

A
  • Distal diaphysis of the left radius
  • Distal metaphysis of the left ulna

Two fractures.

39
Q

Describe this fracture location

A
  • Medial aspect of the distal tibial metaphysis
  • Distal 1/3 of the fibular diaphysis

Two fractures

40
Q

What are the types of orientation/direction for a fx? (6)

A
  • Transverse/simple: perpendicular to shaft
  • Oblique: angulated
  • Spiral: multiplanar and complex
  • Comminuted: 2+ fracture fragments
  • Segmental: subtype of comminuted when it isolates a segment of bone
  • Avulsed: Detached bone fx d/t excessive pulling of ligament, tendon, or joint capsule from attachment point.

Spiral fx may suggest child abuse

41
Q

What condition is compression fx MC with?

A

Osteoporosis

42
Q

What is an intra-articular fx?

A

Crossing articular cartilage into joint

43
Q

Describe this fx location + orientation

A

Transverse fx of mid-shaft diaphysis of the humerus

44
Q

Describe this fx location and orientation

A

Spiral fx of the mid-shaft diaphysis of the femur

45
Q

Describe this fx location and orientation

A

Oblique fx of the diaphysis of the proximal phalanx of the 2nd digit

46
Q

Describe this fx location and orientation

A

Compression fx of the 2nd lumbar vertebrae

47
Q

Describe this fx location and orientation

A

Segmental fracture of the tibial diaphysis

Also a fibular fx

48
Q

What does it mean when a fracture is displaced?

A

No longer in anatomic alignment.

We discuss in reference to the distal displaced fragment

49
Q

Describe how an angulated or displaced fx is described

A

Degree and direction of deviation of the DISTAL fragment.

You can have angulation w/o displacement and vice versa

50
Q

What is a bayoneted/shortened fx?

A

Distal fragment longitudinally overlaps proximal by mm/cm

51
Q

What is a distracted fx?

A

Distal fragment is separated from proximal fragment by a gap in mm/cm

52
Q

How is rotational deformity usually detected?

A

Upon PE

53
Q

Describe the displacement of this fx

A

100% lateral displacement with 30deg medial angulation

54
Q

Describe the displacement of this fx

A

25% ventral displacement without angulation

55
Q

Describe this fx’s location, displacement, and orientation

A
  • Transverse fx of the mid-shaft diaphysis of the femur.
  • 100% medial displacement with shortening.
  • No angulation
56
Q

Describe this fx’s location, displacement, and orientation

A
  • Oblique fx of distal 1/3 of diaphysis of radius
  • 100% lateral displacement with shortening and 30deg of ventral/volar angulation
57
Q

Describe this fx’s location, displacement, and orientation

A
  • Comminuted tibial fx at the mid-diaphysis with 100% medial displacement without angulation.
  • Oblique fibular fx at the mid-diaphysis with 100% medial displacement and 10deg of medial angulation
58
Q

Features of a torus/buckle facture (3)

A
  • Incomplete fx along distal metaphysis
  • MC in distal radius
  • May require multiple XRAY views due to how subtle it is

Metaphysis more spongy. MC in Children

59
Q

Features of a greenstick fracture

A
  • Fx with incomplete extension through periosteum
  • MC in children
  • Fracture on tension side and a buckle on other side of the shaft of a long bone.
60
Q

What is salter-harris classification?

A

Describe fx involving the growth plates

Best done by comparing unaffected side

61
Q

When do growth plates close?

A
  • Females: 12-14
  • Males: 14-16
62
Q

Salter-harris mnemonic

A
  1. S (slipped type 1): Straight across
  2. A: (above type 2): Does not affect joint
  3. L (Lower type 3): Affects the joint
  4. TE (Through everything type 4)
  5. R (Rammed Type 5)
63
Q

Salter-harris classification

A

Type 1

Slipped/straight across

64
Q

Salter harris classification

A

Type 4

Through everything

65
Q

Salter Harris classification

A

Type 3

Lower

66
Q

Salter Harris classification

A

Type 2

Above

67
Q

Salter Harris Classification

A

Type 5

Rammed

68
Q

In the inflammatory phase of fx healing, when is it at its peak and what is happening?

Stage 1

A

Peaks after several days, forming granulation tissue at hematoma site.

69
Q

What occurs in the reparative phase of fx healing? (4)

Stage 2

A
  1. Neovascularization
  2. Collagen production and debris cleanup
  3. Soft callus production
  4. Mineralization of soft callus into hard callus/immature bone
70
Q

What occurs in the remodeling phase of fx healing? (2)

Stage 3

A
  1. Immature bone replace with mature, lamellar bone
  2. Occurs around weeks 6-10, overlapping with repair

Bone does not scar due to continuous remodeling. Only tissue that works like this.

71
Q

When is emergent referral to ortho indicated for fx?

A
  • Open
  • Displaced
  • Unstable
  • Irreducible fx
  • Compartment syndrome
  • Vascular injury
72
Q

What 4 factors guide closed fx management?

A
  • Bone involved
  • Type of fx
  • Degree of displacement
  • Open vs closed
73
Q

Management of a closed axial fx (2)

A
  • Bed rest
  • Non-weight bearing

Hip, pelvis, spine

74
Q

Management of closed extremity fx (6)

A
  • Reduction of displacement or angulation
  • Open reduction internal fixation (ORIF) if surgical needed
  • Immobilization
  • Bed rest
  • Elevation
  • Avoidance of weight-bearing
75
Q

Management of open fracture (6)

A
  1. Emergent Ortho referral
  2. Risk of osteomyelitis, compartment syndrome, and/or NV injury
  3. Irrigation/debridement
  4. Sterile dressing
  5. NPO
  6. Pain meds
76
Q

What empiric ABX is used for open fx grade 1 and 2?

Gustilo anderson classification

A

Cefazoline/Ancef 1g q6-12h

If risk of anaerobic, add metronidazole (farm injury, necrosis)

77
Q

What empiric abx is used for a type 3 open fx?

Gustilo anderson classification

A

Cefazolin + gentamicin (aminoglycoside)

Add metro if risk of anaerobe

Type 3 = high energy damage pattern

78
Q

What are the bad prognostic factors for a fx? (6)

A
  • Skeletal maturity (older ppl cant remodel as well)
  • Fx of multiple bones
  • Intra-articular fx
  • Marked displacement
  • Unstable vertebral
  • Comminuted, oblique, or segmental
79
Q

What is a malunion and how is it treated?

A
  • Inadequate alignment when healing a fx
  • Requires osteotomy or bone cuts to restore alignment
80
Q

What is considered nonuion and what is the tx? (3)

A
  • Lack of healing within 6 months of an injury
  • No healing progress within 3 consecutive months.
  • Tx: surgical fixation, bone graft, electrical/US stimulation
81
Q

What factors might result in nonunion of a fx? (6)

A
  • Smoking
  • Indolent infection
  • Inadequate immobilization
  • Malnutrition
  • Excessive NSAID use
  • Soft tissue injury
82
Q

In what kind of fx is arthritis MC?

A

Intra-articular fx

83
Q

Who is a stress fx MC in?

A

Runners

84
Q

How do stress fractures present? (4)

A
  • Little activity produces pain
  • Localized tenderness over injury site
  • Gradual onset
  • No improvement with conservative therapy
85
Q

Why is a stress fx hard to image?

A
  • Tiny, so does not always show up on XRAY for weeks.
  • CT/MRI is best if you have a high suspicion and need to confirm dx from XR
86
Q

What are low-risk stress fx locations and management?

A
  • 2nd-4th metatarsal shafts
  • Posteromedial tibial shaft
  • Fibula
  • Proximal humerus or shaft
  • Ribs, sacrum, pubic rami
  • Conservative management
87
Q

Where is a high risk stress fracture and management?

A
  • Pars interarticularis of lumbar
  • Femoral head or neck
  • Patella
  • Anterior cortex of tibia
  • Medial malleolus
  • Talus, tarsal or navicular
  • Prox 5th metatarsal shaft, great toes sesamoids, base of 2nd metatarsal bone
  • Surgery

Most of those are heavy weight bearing or used continuously

88
Q

Indications for splinting

A
  1. Fx
  2. Dislocation
  3. Severe sprain
89
Q

Prior to splinting, what should you assess? (2)

A
  • Physical inspection of site
  • Check sensation and pulses
90
Q

When are plaster and fiberglass splints used?

A

Splint that must remain in place for more than a few hours.

91
Q

When is casting indicated? (3)

A
  • Closed
  • Nondisplaced
  • Reduced

Fx

92
Q

When is a cast placed?

A
  1. After swelling resolves
  2. Probably 5-7 days post injury for a stable fx
93
Q

Patient education pearls for casting

A
  • Keep dry
  • Return to have cast removed

MSK (27 decks)

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