MSK Injuries Flashcards
difference between strain vs sprain
- strain: Injury involving the muscle or muscle-tendon unit
- sprain: Trauma to the ligaments that connect bones of a joint
MC strain
Distal muscle tendon junction injury MC
MC sprains
ankle, knee, and wrist during sports activities
strains are MC in muscles attached to ?
2 joints
MOA of strain
Forceful eccentric loading of the muscle
Ex: running, jumping, kicking
MOA of sprain
Joint is overextended; ligament is overstretched
ligament sprain is uncommon in what pt demographic? (2)
why?
children and older adults
They have weaker bones = avulsion or growth plate fractures
RF for strains and sprains (9)
- poor ergonomics
- environment
- increased age w/ reduced physical activity
- deconditioned or unstretche muscles
- specific activities
- overuse
- body habitus
- fatigue
- previous injury
Pts often report a popping, snapping, or tearing sensation at the time of the event
followed by pain, swelling, stiffness, and difficulty bearing weight/reduced ability to use the extremity involved
Bruising + discoloration may appear within 24-48 hours
hx of what dx?
strains & sprains
- Asymmetric swelling, tenderness, and ecchymosis of injured area
- Visible and/or palpable defect may be seen/felt
- Pain with active and passive flexion of the muscle
- Loss of active muscle contraction to move joint→ complete rupture of the muscle
PE of what dx?
muscle strain
- Asymmetric swelling, tenderness, and ecchymosis of injured area
- Pain with active and passive ROM
- Joint instability/laxity
- Special tests may be beneficial
PE of what dx?
ligament sprain
muscle strain grading
- Grade 1: Tear of a few muscle fibers (< 10%), fascia intact
- Grade 2: Tear of moderate amount of muscle fibers (10-50%), fascia intact
- Grade 3: Tear of most/all fibers (50-100%), fascia intact
- Grade 4: Tear of all muscle fibers (100%), fascia disrupted
ligament sprain grading
- Grade 1: Mild; a tear of only a few fibers of the ligament; no joint instability
- Grade 2: Moderate; partial tear of the ligament; some laxity with stress maneuvers
- Grade 3: Severe; complete tear of the ligament; joint laxity with stress maneuvers
how to dx strains/sprains
- Most often clinical
- Labs and imaging are usually not necessary - X-ray if high concern for fracture
indications for XR for strains/sprains
- Positive “Ottawa Ankle Rules”
- Can be generalized to other joints - Worsening pain/swelling with appropriate management
- Persistent pain/swelling after 7-10 days of appropriate management
ottawa ankle rules for ankle sprains
- pain at the medial malleolus or along distal 6cm of posterior/medial tibia
- pain at lateral malleolus or along distal 6cm of posterior fibula
- inability to bear wt immediately and for 4 consecutive steps in ER
ottawa ankel rules for foot sprains
- pain in midfoot and at base of 5th metatarsal
- pain in midfoot and at navicular bone
- inability to bear wt immediately and for 4 consecutive steps in ER
which dx modality is used to confirm or grade strains/sprains?
indications?
MRI
- suspected rupture or severe pain
- surgical intervention is likely
Healing process is divided into 4 phases:
strains + sprains
- hemostasis
- inflammatory
- proliferative
- maturation
- Onset → immediately after injury
- Platelets aggregate and release cytokines, chemokines, and hormones
- Vasoconstriction - limits bleeding into affected area = temp skin blanching
- Clot formation occurs
which phase of healing process
hemostasis
- Onset → immediately after injury
- Results from tearing of the myofibers, ligament fibers, and microvasculature
- Bleeding and necrosis of the soft tissue = inflammatory cascade
- Homeostasis of fluid balance is disrupted resulting in swelling
- Capillaries dilate and become more permeable → increase in blood transmission into the extravascular space (bruising) & increase in the concentration of local inflammatory mediators
which phase of healing process?
how long does this last?
Inflammatory/Destruction Phase (0-72 hrs post injury)
- Granulation tissue is formed - Collagen deposition occurs
- Neovascularization occurs at the injury, supporting tissue healing
- Inflammatory mediators are reduced
which phase of the healing process?
how long does this last?
Proliferative/Reparative/Fibroblastic Phase (72 hrs - 3 wks)
Collagen and myofibers increase in number, strength, and organization
which phase of healing process?
how long does this last?
Maturation/Remodeling Phase (3 wks - 2 yrs)
management goals during Hemostasis / Inflammatory Phase (day 0-3)
→ Protection / compression of the injured area and rest
→ Control pain and swelling = ICE!
management goals during reparative phase (day 3 - wk 3)
→ Continued protection with pain and swelling control
→ Full AROM
→ Progressive muscular strength, endurance and power
management goals during maturation phase (wk 3 - 2 yrs)
→ Maintenance of ROM and flexibility
→ Increased muscular strength, endurance and power
→ Increased speed and agility
management for strains+sprains
-
Surgical repair - for complete tears
- Refer if joint instability, failure of conservative therapy, neurovascular compromise - Pain - NSAIDS 1st line
- Opioids based on severity of pain/injury -
PRICE
- Weight-bearing, ROM exercise, and strength training should begin
- Consider a referral to PT
components of PRICE
indicated in the inflammatory phase of healing
- Protection → Padding, slings, braces, ACE wraps, air splint
- Rest → No additional force should be applied; avoid weight bearing
- Ice → ASAP to reduce pain and swelling through vasoconstriction
- Compression → ACE to limit swelling
- Elevation → ideally “above the heart”
how long to ice for PRICE?
CI?
avoid what during this phase?
- 15-20 min q2-3h for first 48 hrs
- CI: Raynaud’s, PVD, impaired sensation, cold allergy/hypersensitivity, severe cold induced urticaria
- Heat should be avoided during this phase; avoid direct contact with skin with ice
MOA of overuse syndrome
- Repetitive motions, stresses, or sustained exertion of that body part
- Repetitive microtrauma to the muscle or tendon leading to an acute or chronic degenerative state
overuse syndrome is presented MC in who?
athletes
The sport may lead to your dx
extrinsic causes of overuse syndrome
- Repetitive mechanical load - Increased duration, frequency, increased intensity, technique errors
- Equipment problems - Poor footwear, racquet size, running surface
instrinsic causes of overuse syndrome
- Anatomic factors - Malalignment, inflexibility, muscle weakness, muscle imbalance, decreased vascularity
- Age-Related Factors - Tendon degeneration, decreased healing response, increased tendon stiffness
- Systemic Factors - Inflammatory disorders, quinolone-induced tendinopathy
presentation of overuse syndrome
-
Pain, muscle fatigue, numbness, swelling
- Sx tend to develop and slowly progress over time
- Pain may be localized to tendinous insertion and exacerbated by muscle stretch or contraction
w/u for overuse syndrome?
findings?
- H&P is crucial to dx
- PE: muscle testing, ROM, and special testing if indicated
-
Diagnostic testing
- Radiograph - calcification or spur formation of the tendon at insertion site
- Bone scans and MRI’s - Stress fractures, osseous pathology
- NCS/EMG’s - if neurologic s/s
management for overuse synrome
- Most are mild and will resolve spontaneously
- Avoidance of the activity that led to syndrome
- Pain management → ice/heat, NSAIDS, corticosteroid injections
- PT - home exercise programs
- OT - workplace modifications
- Referral to Ortho if conservative tx fails
Thick outer layer that contains vessels, nerve endings and cells that repair fractures
periosteum
Inner lining of the marrow cavity
endosteum
Contains the epiphyseal plate (growth plate/physis)
Very vascular and prone to infection and fractures
epiphysis
Consists of spongy, cancellous bone
Most susceptible to compression fractures
Metaphysis
Thick cortical bone
Provides most of the structural support of the long bone
Diaphysis
Defined as disruption in the continuity or structural integrity of a bone
fractures
MOA of fractures
- Stress applied to the bone is greater than the bone’s intrinsic strength
- Can also occur pathologically
for fractures, ALWAYS inspect bones/joint ___ and ___ injury!
above
below
imaging fo fractures
- 1st line → radiograph
- CT or MRI → indicated if dx needs confirmed or to further define a complex fracture prior to surgical repair
Components of Describing a Fracture:
- open vs closed
- location
- orientation/direction - Fractures with multiple parts; Comminuted versus segmented; Compression or impaction
- displacement - Degree of angulation; Direction of angulation
how to determine if a fracture is open vs closed?
Gustilo and Anderson Classification
- Grade I - Low energy injury with an open wound < 1 cm in length and no contamination
- Grade II - Moderate injury with comminution of the fracture and a 1-10-cm wound with some contamination
- Grade IIIA - High-energy fracture pattern with a wound >10 cm and gross contamination
- Grade IIIB - High-energy fracture with a >10 cm contaminated wound with exposed bone
- Grade IIIC - Similar to grade IIIB with vascular involvement
how to describe location of fracture
- Diaphysis / “shaft” - Location on bone shaft
- Distal or proximal metaphysis
- Epiphysis / growth plate
- Anatomical name of the bone - Ex: olecranon process
fx perpendicular to the shaft of the bone
which fracture orientation/direction
Transverse (Simple)
angulated fracture line
oblique
multiplanar and complex fracture line
spiral
fx in which there are more than two fracture fragments
Comminuted
type of comminuted fx in which there are 2 fracture lines isolating a segment of bone
Segmental
a detached bone fragment that results from the excessive pulling of a ligament, tendon, or joint capsule from its point of attachment on a bone
Avulsed
common with osteoporosis
Type of impaction fracture that occurs in the vertebrae
what type of fracture orientation/direction
compression
crosses the articular cartilage and enters the joint
which fracture orientation/direction
Intra-articular
difference between the displacements of a fracture
- Nondisplaced → fragments are in anatomic alignment
- Displaced → fracture is no longer in anatomic alignment
for displaced fractures, Note severity in mm or % with regard to the direction the ___ fragment is offset in relation to the proximal fragment
DISTAL
Bone fragments are misaligned
Described as degree and direction of deviation of the distal fragment
angulated
- medial
- lateral
- ventral
- dorsal
Distal fragment longitudinally overlaps the proximal fragment
Bayoneted (Shortened)
Distal fragment is separated from the proximal fragment by a gap
Distracted
Degree the distal fragment is twisted on axis of normal bone
Usually detected by physical exam
Rotational deformity
An incomplete fracture along the distal metaphysis where the bone is most spongy
TORUS (BUCKLE) FRACTURE
TORUS (BUCKLE) FRACTURE MC happens in what structure?
distal radius
torus fracture may be very subtle therefore it is important to do what with XR?
look at multiple views on x-ray
- A fracture that doesn’t extend through the entire periosteum
- Occurs in the pediatric population due to soft bone
- A fracture on the tension side and a buckle on the other side of the shaft of a long bone
GREENSTICK FRACTURE
Used to describe fractures involving the growth plate
salter-harris classification
- Lack of ossification of epiphyses in young children can make fracture identification difficult
- Comparison of unaffected side can assist in detecting fractures in skeletally immature children
when does the growth plate close in females and males?
Females - 12-14 years old
males - 14-16 years old
SALTER-HARRIS MNEMONIC
- **S: slipped (type I) ** - some people say “straight across”
- A: above (type II) - does not affect the joint
- L: lower (type III) - affects the joint
- TE: through everything (type IV)
- R: rammed (type V)
3 fracture healing phases
- Stage 1: Inflammatory Phase
- Stage 2: Reparative Phase
- Stage 3: Remodeling Phase
- Immediately → bleeding from the fracture site and surrounding tissue
- Peaks after several days - bioactive cells migrate to fracture site hematoma leading to formation of granulation tissue
which phase of fracture healing?
Stage 1: Inflammatory Phase
- Neovascularization promotes the healing process
- Necrotic debris is removed by phagocytes and fibroblasts begin to produce collagen
- Soft callus is produced first and then mineralization begins to occur slowly converting to woven/immature bone
which phase of fracture healing
Stage 2: Reparative Phase
- Overlaps with repair phase and can continue for several months
- Woven (immature) bone is replaced with more mature lamellar bone - Typically occurs around 6-10 weeks
which phase of fracture healing
Stage 3: Remodeling Phase
Indications for immediate orthopedic consultation
- Open, displaced, unstable or irreducible fractures
- Fractures complicated by compartment syndrome, nerve, or vascular injury
closed fracture management is guided by 4 factors:
- Bone involved
- Type of fracture
- Degree of displacement
- Open vs. Closed
management for closed axial fracture
Bed rest and non-weight bearing
management for closed extremity fracture
- Reduction if displaced or angulated
- Mod-severe displacement/angulation requires surgical intervention - Open reduction and internal fixation (ORIF) with plates, screws, pins or intramedullary devices
- Immobilization
- Bed rest, elevation, avoidance of weight bearing
- Further evaluation by a specialist
open fracture management
- EMERGENCY!
- irrigation/debridement followed by application of sterile dressing
- NPO, Pain medication
- IV Abx
- update Td
open fractures are at high risk of what complications?
osteomyelitis, compartment syndrome and neurovascular injury
abx for type I and II fractures
1st gen ceph: Cefazolin (Ancef) 1 g every 6-12h
abx for type III fracture
1st gen ceph + Aminoglycoside (gentamicin)
abx for open fracture If at risk for anaerobic infection (e.g. farm injury, necrosis)
Add metronidazole
adverse outcomes of fractures
- malunion
- nonunion
- stiffness, muscle atrophy
- arthritis
- vascualr or nerve injury
- compartment syndrome
- osteonecrosis
Factors that worsen fracture prognosis
- Skeletal maturity
- Fractures of multiple bones in the extremity
- Intra-articular fractures
- Marked displacement of fractures
- Unstable vertebral fractures
- Comminuted, oblique and segmental fractures
diagnostic criteria for nonunion fractures
- Lack of healing within 6 months of an injury
- No healing progress in 3 consecutive months
factors that affect healing causing nonunion fracture
Smoking, indolent infection, inadequate immobilization, malnutrition, NSAID use significant, soft tissue injury
tx for nonunion fracture
Surgical fixation, bone graft, electrical/US stimulation
Inadequate alignment of a fracture
Results from inappropriate reduction, immobilization or surgical error in alignment
dx?
tx?
- malunion
- osteotomy or bone cuts to restore anaomical alignment
A fracture in normal bone that has been subjected to repeated or continuous loads that in and of themselves are not sufficient to cause a fracture
Common in athletes, esp runners
stress fracture
causes of stress fx
- Small number of repetitions with a relatively large load
- A large number of repetitions with a usual load
RF for stress fx
- Prior stress fracture
- Low level of fitness
- Increasing volume and intensity of physical activity
- Female gender, especially when combined with menstrual irregularity
- Eating disorders (female athlete triad)
- Diets poor in calcium and vitamin D
- Poor bone health
- Poor biomechanics
H&P of stress fx
- A thorough history can typically provide the diagnosis
- Pain - Gradual onset, localized; Worse with significant activity, initially; Less activity can produce pain as fracture progresses
- Localized tenderness over injury site
if doubting stress fx dx, proceed to ?
imaging
- Plain radiographs should be obtained initially due to high specificity - May not appear on radiograph for several weeks
- If suspicion is high and diagnosis needs confirmed, proceed with MRI, CT or bone scan
Conservative management is used for these low-risk stress fractures:
- Fx of the 2nd-4th metatarsal shafts
- Posteromedial tibial shaft
- Fibula
- Proximal humerus or humeral shaft
- Ribs, sacrum and pubic rami
Types of Conservative Therapy for stress fx
- Acute pain control
- Reduced weight bearing or splinting
- Reduction or modification of activities
- Rehabilitative exercise to promote optimal biomechanics
- Reduce risk factors
Surgery is needed for these high-risk stress fractures:
- Pars interarticularis of lumbar spine
- Femoral head and neck
- Patella
- Anterior cortex of tibia
- Medial malleolus
- Talus, tarsal navicular
- Prox 5th metatarsal shaft, great toes sesamoids, base of second metatarsal bone
Referral to orthopedist should be done immediately if :
→ High risk fractures
→ When a lengthy rehab program is inappropriate
→ Conservative treatment fails
indications for splinting
- Fractures
- Dislocations
- Severe Sprains
the preferred splint of choice when a splint is expected to remain in place for more than a few hours
Plaster and Fiberglass splints
instructions on how to splint?
- Remove clothing to fully inspect the area
- Check NV status distal to the injury before & after splint
- Clean all wounds and cover with a dry, sterile dressing
- Immobilize the joint above and below the fracture bone
- Intra-articular fx - immobilize the bones above and below the joint fx
- Pad all rigid splints to prevent local injury
- While applying the splint - Minimize movement of the limb; Support injury site until the splint has set
- Attempt to reduce any severely deformed limb with constant gentle traction - If resistance is encountered, splint in position of deformity
types of splinting
Prefabricated plastic splints, air splints, fabric splints and metal splints
splinting materials
- Cast padding and stockinette (ALWAYS)
- Prefabricated plaster or fiberglass splints
- Rolls of plaster or fiberglass splinting material
- Elastic bandage
- Water (warm water will speed setting time)
- Non-sterile gloves
- Standard of treatment for many closed, nondisplaced/reduced fractures
- Optimal timing for cast placement is after swelling has resolved, which may take 5-7 days, unless fracture is unstable - Splints are useful in the meantime
what type of tx?
casting
casting materials
- Stockinette
- Cast padding
- Fiberglass or plaster casting “tape”
casting pearls
- Application is very similar to splinting
- ALWAYS note neurovascular status!
- Follow up x-rays help document continued bone healing and union
- Important to tell patients to keep both splints and casts DRY!
- Patient’s must return to have cast removed
