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MSK > MSK Injuries > Flashcards

MSK Injuries Flashcards

1
Q

MSK injuries fall into what categories?

A
  • Direct (contact) or indirect (non-contact)
  • Muscle strain
  • Ligamentous sprain
  • Fracture
  • Contusion/hematoma
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2
Q

Keys to approaching MSK injuries

A
  • Rule out emergency
  • Rule out fracture
  • Manage conservatively
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3
Q

What is a muscle strain?

A
  • Pulled muscle
  • Injury involving the muscle or muscle-tendon unit
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4
Q

Where is a muscle strain mc?

A
  • distal muscle tendon junction injury
  • In muscles attached to 2 joints
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5
Q

MOA causing muscle strain

A

Forceful eccentric loading of the muscle

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6
Q

What is a ligament sprain?

A

Trauma to the ligaments that connect bones of a joint

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7
Q

Where are the most common ligament sprains?

A
  • Ankle
  • Knee
  • Wrist during sports activities
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8
Q

MOA of ligament sprain

A

Joint overextended; ligament overstretched

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9
Q

Ligament sprains are uncommon in children and older adults. Why?

A

Children and older adults tend to have weaker bones than ligaments, leading to avulsion fractures rather than ligament sprains

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10
Q

Risk factors for strains and sprains

A
  • Poor ergonomics
  • Deconditioned or unstretched muscles
  • Body habitus
  • Environment
  • Specific activities
  • Fatigue
  • Increased age with reduced physical activity
  • Overuse
  • Previous injury
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11
Q

History in strains and sprains

A
  • Popping, snapping, or tearing sensation at time of event
  • Followed by pain, swelling, stiffness
  • Difficulty bearing weight/reduced ability to use the extremity involved
  • Bruising and discoloration may appear within 24-48 hours
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12
Q

Physical exam findings for both strains and sprains

A
  • Asymmetric swelling
  • Tenderness
  • Ecchymosis
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13
Q

Physical exam findings for muscle strain

A
  • 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
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14
Q

Physical exam findings with ligament sprain

A
  • Pain with active and passive ROM
  • Joint instability/laxity
  • More common for higher grade (III) sprains
  • Special tests may be beneficial to determine specific ligament
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15
Q

What is a grade 1 muscle strain?

A

Tear of a few muscle fibers (<10%); fascia intact

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16
Q

What is a grade 2 muscle strain?

A
  • Tear of moderate amount of muscle fibers (10-50%), fascia intact
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17
Q

What is a grade 3 muscle strain?

A
  • Tear of most or all fibers (50-100%), fascia intact
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18
Q

What is a grade 4 muscle strain?

A

Tear of all muscle fibers (100%), fascia disrupted

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19
Q

What is a grade 1 ligament sprain?

A

Mild; a tear of only a few fibers of the ligament; no joint instability

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20
Q

What is a grade 2 ligament sprain?

A

Moderate; partial tear of the ligament; some laxity with stress maneuvers

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21
Q

What is a grade 3 ligament sprain?

A
  • Severe; complete tear of the ligament
  • Joint laxity with stress maneuvers
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22
Q

Diagnosis of strains and sprains

A
  • Most often clinical, labs and imaging not necessary
  • X-ray utilized if high concern for fracture
  • MRI to confirm or grade strains/sprains
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23
Q

Indications for X-ray in suspected strain/sprain

A
  • Positive Ottawa Ankle Rules
  • Worsening pain/swelling with appropriate management
  • Persistent pain/swelling after 7-10 days of appropriate management
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24
Q

Ottawa ankle rules

A

Ankle Sprains:
* Pain at medial malleolus or along distal 6 cm of the posterior/medial tibia
* Pain at the lateral malleolus or along the distal 6 cm of the posterior fibula
* Inability to bear weight immediately and for four consecutive steps in the emergency department

Foot sprains:
* Pain in the midfoot and at the base of the fifth metatarsal
* Pain in the midfoot and at the navicular bone
* Inability to bear weight immediately and for four consecutive steps in the emergency department

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25
Q

Indications for MRI for strains and sprains

A
  • Suspected rupture or severe sprain
  • Surgical intervention is likely
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26
Q

Healing process of strains and sprains

A
  • Phase 1: hemostasis
  • Phase 2: inflammatory phase
  • Phase 3: proliferative phase
  • Phase 4: maturation phase
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27
Q

Pathophysiology of phase 1 of strains and sprains

A
  • Hemostasis
  • Platelets aggregate and release cytokines, chemokines, and hormones
  • Vasoconstriction occurs to limit bleeding into affected area causing temporary skin blanching
  • Clot formation occurs
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28
Q

Pathophysiology of phase 2 of strains/sprains

A
  • Onset 0-72 hours post injury
  • Inflammatory/Destruction phase
  • Results from tearing of the myofibers, ligament fibers, and microvasculature
  • Bleeding and necrosis of the soft tissue induces an 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 and increase in the concentration of local inflammatory mediators
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29
Q

Pathophysiology of phase 3 of strains and sprains?

A
  • 72 hrs - 3 weeks
  • Proliferative/reparative/fibroblastic phase
  • Granulation tissue formed
  • Collagen deposition occurs
  • Neovascularization at the injury, supporting tissue healing
  • Inflammatory mediators are reduced
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30
Q

Pathophysiology of phase 4 of strains and sprains

A
  • 3 wks - 2 yrs
  • Maturation/remodeling phase
  • Collagen and myofibers increase in number, strength, and organization
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31
Q

Management of hemostasis/inflammatory phase (day 0-3)

A
  • Protection/compression of the injured area and rest
  • Control pain and swelling ICE
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32
Q

Management of reparative phase (day 3-week 3)

A
  • Continued protection with pain and swelling control
  • Full AROM
  • Progressive muscular strength, endurance, and power
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33
Q

Management of maturation phase of strains and sprains (wk 3- 2 years)

A
  • Maintenance of ROM and flexibility
  • Increased muscular strength, endurance and power
  • Increased speed and agility
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34
Q

What is indicated in inflammatory phase of healing

A

PRICE
* 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 for 15-20 minutes every 2-3 hours for the first 48 hours
* Compression: compression bandages (ACE) to limit swelling
* Elevation: ideally above the heart
* Heat should be avoided during this phase

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35
Q

Contraindications to ice in the inflammatory phase

A
  • Raynaud’s
  • PVD
  • Impaired sensation
  • Cold allergy/hypersensitivity
  • Severe cold induced urticaria
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36
Q

Treatment of complete tear of muscle, tendon, or ligament

A
  • Surgical repair
  • Refer if joint instability, failure of conservative therapy, neurovascular compromise
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37
Q

What can be used for pain management in strains/sprains?

A
  • NSAIDs first line
  • Opioids may be needed based on severity of pain/injury
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38
Q

What should be done following PRICE?

A
  • Weight-bearing
  • ROM exercise
  • Strength training
  • Start low and go slow
  • Consider referral to physical therapy
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39
Q

What is overuse syndrome

A

Umbrella term encompassing diagnosis that results from overuse of a musculoskeletal component

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40
Q

MOA of overuse syndrome

A
  • 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
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41
Q

Who more likely gets overuse syndrome

A
  • Very common with athletes
  • Sport may lead to your diagnosis
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42
Q

Extrinsic factors causing overuse syndrome?

A
  • Repetitive mechanical load
  • Increased duration, frequency, intensity, technique errors
  • Equipment problems: poor footwear, racquet size, running surface
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43
Q

What anatomic factors can cause overuse syndrome?

A
  • Malalignment
  • Inflexibility
  • Muscle weakness
  • Muscle imbalance
  • Decreased vascularity
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44
Q

Age-related factors causing overuse syndrome

A
  • Tendon degeneration
  • Decreased healing response
  • Increased tendon stiffness
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45
Q

Systemic factors causing overuse syndrome

A
  • Inflammatory disorders
  • Quinolone-induced tendinopathy
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46
Q

Presentation of overuse syndrome

A
  • Pain
  • Muscle fatigue
  • Numbness
  • Swelling
  • Symptoms tend to develop and slowly progress over time
  • Pain may be localized to the tendinous insertion and exacerbated by muscle stretch or contraction
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47
Q

Work up of overuse syndrome

A
  • Thorough and complete H&P considering aggravating/alleviating factors, repetitive activities, work environments
  • PE: muscle testing, ROM, and special testing if indicated
  • Radiograph: calcification or spur formation of tendon at insertion site
  • Bone scans and MRIs: stress fractures, osseous pathology
  • NCS/EMGs: if neurologic s/s
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48
Q

Management of overuse syndrome

A
  • Most are mild and will resolve spontaneously
  • Avoidance of the activity that led to syndrome
  • Patient education
  • Pain management –> ice/heat, NSAIDs, corticosteroid injections
  • PT: home exercise programs
  • OT: workplace modifications
  • Referral to ortho if conservative tx fails
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49
Q

What is the periosteum

A
  • Thick outer layer
  • Contains vessels, nerve endings and cells that repair fractures
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50
Q

What is the endosteum

A
  • Inner lining of the marrow cavity
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51
Q

What is the epiphysis?

A
  • Contains epiphyseal plate (growth plate/physis)
  • Very vascular and prone to infection and fractures
  • Present on child at end of growth plate and not on adult
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52
Q

What is metaphysis

A
  • Spongy, cancellous bone
  • Most susceptible to compression fractures
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53
Q

What is diaphysis

A
  • Thick cortical bone
  • Provides most of the structural support of the long b one
54
Q

What is a fracture

A

Disruption in the continuity or structural integrity of a bone

55
Q

MOA of fractures

A
  • Stress applied to the bone greater than the bone’s intrinsic strength
  • Can also occur pathologically
  • All bones can fracture but extremities at highest risk
56
Q

History in fractures

A
  • Often hx of trauma
  • Pain worsened by movement
  • Localized tenderness
  • +/- deformity
  • +/- numbness/tingling
57
Q

Physical exam in fractures

A
  • Always inspect bones/joint above and below injury
    Inspection
  • Edema, ecchymosis
  • Deformity
  • Skin integrity

Palpation
* Tenderness, crepitus
* Evaluate joint stability
* Assess NV status

58
Q

Imaging for fractures

A
  • First line: radiograph
  • CT or MRI –> indicated if diagnosis needs confirmed or to further define a complex fracture prior to surgical repair
59
Q

Components of describing a fracture

A
  • Open vs closed
  • Location
  • Orientation/direction: communuted vs segmented, compression vs impaction
  • Displacement: degree of angulation and direction
60
Q

Gustilo and Anderson classification grade I

A
  • Low energy injury with an open wound <1 cm in legnth and no evidence of contamination
61
Q

Gustilo and Anderson classification grade II

A
  • Moderate injury with comminution of the fracture and a 1- to 10 cm wound with some contamination
62
Q

Gustilo and Anderson classification grade IIIA

A

High-energy fracture apttern with a wound >10 cm and gross contamination

63
Q

Gustilo and Anderson classification grade IIIB

A

High energy fracture with a >10 cm contaminated wound with exposed bone

63
Q

Grade IIIC gustilo and anderson classification

A

Similar to grade IIIB with vascular involvement

64
Q

Fracture location description

A
  • Diaphysis/shaft: location on bone shaft
  • Distal or proximal metaphysis (end of adult bone or neck of child)
  • Epiphysis/growth plate
  • Anatomical name of the bone
65
Q

Transverse fracture

A

Fracture perpendicular to the shaft of the bone

66
Q

Oblique fracture

A

Angulated fracture line

67
Q

Spiral fracture

A

Multiplanar and complex fracture line

68
Q

Comminuted fracture

A

Fracture in which there are more than two fracture fragments

69
Q

Segmental comminuted fracture

A

Type of comminuted fracture in which there are 2 fracture lines isolating a segment of bone

70
Q

Avulsed fracture

A

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

71
Q

Compression fracture

A

Common with osteoporosis type of impaction that occurs in the vertebrae

72
Q

Intra-articular fracture

A

Crosses the articular cartilage and enters the joint

73
Q

Non-displaced

A

Fragments are in anatomic alignment

74
Q

Displaced

A

Fracture is no longer in anatomic alignment

75
Q

How is severity of displaced fracture annotated?

A

in mm or % with regard to the direction the distal fragment is offset in relation to the proximal fragment

76
Q

Angulated fracture displacement

A
  • Bone fragments are misaligned
  • Described as the degree and direction of deviation of the distal fragment
  • Could be medial, ventral, lateral, dorsal
77
Q

Bayoneted fracture displacement

A

Distal fragment longitudinally overlaps the proximal fragment

78
Q

Distracted fracture displacement

A

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

79
Q

Rotational deformity displacement

A
  • Degree the distal fragment is twisted on axis of normal bone
  • Usually detected by physical exam
80
Q

Make sure to look at the practice displacement questions to ensure you understand!

A

Okay fine!

81
Q

What is a torus (buckle) fracture?

A
  • Incomplete fracture along distal metaphysis where bone is most spongy
  • MC in distal radius
  • May be very subtle –> important to look at multiple views on x-ray
  • Common in pediatrics
82
Q

What is a greenstick fracture?

A
  • Common in pediatrics
  • Fracture that doesn’t extend through the entire periosteum
  • Occurs in pediatric population due to soft bone
  • Fracture on the tension side and buckle on the other side of the shaft of a long bone
83
Q

Salter-Harris classification

A
  • Used to describe fractures involving growth plate
84
Q

When does growth plate closure usually occur?

A
  • Depends on specific bone and age of patient
  • Females average 12-14
  • Males 14-16
85
Q
A
86
Q
A
87
Q
A
88
Q

Go back and look over Salter Harris classification!

A

Got it!

88
Q

What can assist in detecting fractures in skeletally immature children?

A

Comparison of unaffected side

lack of ossification of epiphyses in young children can make fracture identification difficult

88
Q

Salter harris classification mneumonic

A
  • S: slipped (type I) - some people say straight across, through growth plate
  • A: above (type II), does not affect joint, through growth plate and metaphysis
  • L: lower (type III), affects the joint, through growth plate and epiphysis
  • TE: through everything (type IV), through all three elements
  • R: rammed (type V), crush injury of growth plate
89
Q

What are the 3 phases of fracture healing?

A
  • Stage 1: Inflammatory phase
  • Stage 2: reparative phase
  • Stage 3: remodeling phase
90
Q

What are characteristics of the inflammatory phase of fracture healing?

A
  • Immediately bleeding from the fracture site and surrounding tissue occurs
  • Peaks after several days, bioactive cells migrate to fracture site hematoma leading to formation of granulation tissue
91
Q

What are characteristics of reparative phase of fracture healing?

A
  • Neovascularization promotes the healing process
  • Necrotic debris is removed by phagocytes and fibroblasts begin to produce collagen
  • Soft callus produced first
  • Then mineralization begins to slowly convert woven/immature bone
92
Q

What are characteristics of the remodeling phase of fracture healing?

A
  • Overlaps with repair phase and can continue for several months
  • Woven (immature) bone is replaced with more mature lamellar bone
  • Typically around 6-10 weeks
93
Q

Indications for immediate orthopedic consultation with fracture?

A
  • Open fracture
  • Displaced fracture
  • Unstable fracture
  • Irreducible fracture
  • Fractures complicated by compartment syndrome
  • Nerve or vascular injury in fracture
94
Q

What guides closed fracture management?

A
  • Bone involved
  • Type of fracture
  • Degree of displacement
  • Open vs. Closed
95
Q

What is management of axial fracture?

A

Bed rest and non-weight bearing

Hip, pelvis, spine

96
Q

Management of closed extremity fracture

A
  • Reduction if displaced or angulated
  • Moderate-severe displacement/angulation requires surgical intervention with ORIF (open reduction and internal fixation with plates, screws, pins or intramedullar devices)
  • Immobilization: splints, casting, slings
  • Bed rest
  • Elevation
  • Avoidance of weight bearing
  • Further evaluation by a specialist
97
Q

Open fracture management

A
  • Orthopedic emergency!! High risk of osteomyelitis, compartment syndrome, and neurovascular injury
  • Require irrigation/debridement followed by sterile dressing
  • NPO
  • Pain medication
  • Broad spectrum IV antibiotics
  • Update Td if applicable
98
Q

Type I and II open fracture IV antibiotics

A
  • 1st generation cephalosporin: cefazolin
  • If at risk for anaerobic infection, add metronidazole
99
Q

Type III open fracture IV antibiotics

A
  • 1st generation cephalosporin (cefazolin)
  • +aminoglycoside (gentamicin)
  • If at risk for anaerobic infection (ie farm injury or necrosis) add metronidazole
100
Q

Factors that worsen prognosis of fractures

A
  • Skeletal maturity
  • Fractures of multiple bones in the extremity
  • Intra-articular fractures
  • Marked displacement of fractures
  • Unstable vertebral factures
  • Comminuted, oblique, and segmental fractures
101
Q

Adverse outcomes from fractures

A
  • Malunion
  • Nonunion
  • Stiffness, muscle atrophy: early PT can prevent
  • Arthritis: associated with intra-articular fx
  • Vascular or nerve injury
  • Compartment syndrome
  • Osteonecrosis
102
Q

Malunion

A
  • Inadequate alignment of fracture
  • Results from inappropriate reduction, immobilization, or surgical error in alignment
103
Q

Treatment of malunion

A

Osteotomy or bone cuts to restore anatomical alignment

104
Q

Nonunion diagnostic criteria

A
  • Lack of healing within 6 months of a injury
  • No healing progress in 3 consecutive months
105
Q

Factors that affects nonunion healing

A
  • Smoking
  • Indolent infection
  • Inadequate immobilization
  • Malnutrition
  • NSAID use significant
  • Soft tissue injury
106
Q

Treatment options for nonunion fractures

A
  • Surgical fixation
  • Bone graft
  • Electrical/US stimulation
107
Q

What is a stress fracture?

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

108
Q

Causes of stress fracture

A
  • Small number of repetitions with a relatively large load
  • Large number of repetitions with a usual load
  • Common in athletes, especially runners
109
Q

Risk factors for stress fracture

A
  • Prior stress fracture
  • Low level of fitness
  • Increasing volume and intensity of physical activity
  • Female gender, especially when combined with menstrual irregularity (+eating disorder = triad)
  • Eating disorders (female athlete triad)
  • Diets poor in calcium and vitamin D
  • Poor bone health
  • Poor biomechanics
110
Q

History with stress fracture

A
  • Gradual onset, localized pain
  • Worse with significant activity initially
  • Less activity can produce pain as fracture progresses
  • Look at risk factors
111
Q

Physical exam with stress fracture

A

Localized tenderness over injury site

112
Q

Imaging in stress fracture

A
  • If doubting diagnosis
  • Plain radiographs should be obtained initially due to high specificity, may not appear on radiographs for weeks
  • If suspicion high and diagnosis needs confirmed, MRI, CT, or bone scan
113
Q

Management of stress fracture

A
  • Based on fracture site
  • Conservative management for low-risk fractures
  • Surgery for high-risk fractures
114
Q

What locations are considered low-risk fractures?

A
  • Fx of 2nd-4th metatarsal shafts
  • Posteromedial tibial shaft
  • Fibula
  • Proximal humerus or humeral shaft
  • Ribs, sacrum, and pubic rami
115
Q

Conservative therapy for stress fracture

A
  • Acute pain control
  • Reduced weight bearing or splinting
  • Reduction or modification of activities
  • Rehabilitative exercise to promote optimal biomechanics
  • Reduce risk factors
116
Q

High-risk stress fracture locations

A
  • Pars interarticularis of lumbar spine
  • Femoral head and neck
  • Patella
  • Anterior cortex of tibia
  • Medial malleolus
  • Talus, tarsal navicular
  • Proximal 5th metatarsal shaft, great toes sesamoids, base of second metatarsal bone
117
Q

When should referral to orthopedist for stress fracture be done immediately?

A
  • High risk fractures
  • Lengthy rehab program inappropriate
  • Conservative treatment fails
118
Q

Goals of splinting

A
  • Reduce pain, bleeding, and swelling of injury site and surrounding areas
  • Immobilize the injury
  • Prevent further damage of the muscles, nerves and blood supply
  • Prevent further laceration of the skin and contamination of an open wound
118
Q

Indications for splinting

A
  • Fractures
  • Dislocations
  • Severe sprains
119
Q

Splinting instructions

A
  • Remove clothing to fully inspect area
  • Check NV status distal to injury before and after splint
  • Clean all wounds and cover with dry, sterile dressing
  • Immobilize above and below fracture bone
  • Intra-articular fx immobilize above and below joint fracture
  • Pad all rigid splints to prevent local injury
  • While applying splint, minimize movement of the limb and support injury site until splint has set
  • Attempt to reduce any severely deformed limb with constant gentle traction
  • If resistance is encountered, splint in position of deformity
120
Q

Splinting types

A
  • Prefabricated plastic splints
  • Air splints
  • Fabric splints
  • Metal splints
  • Plaster and fiberglass splints
121
Q

What is splint of choice when expected to remain in place for more than a few hours?

A

Plaster and fiberglass splints

122
Q

Splinting materials

A
  • Cast padding and stockinette
  • Prefabricated plaster or fiberglass splints
  • Rolls of plaster or fiberglass splinting material
  • Elastic bandage
  • Water
  • Non-sterile gloves
123
Q

Optimal timing for cast placement

A
  • After swelling has resolved, 5-7 days after unless fracture is unstable
  • Splints useful in meantime
124
Q

Standard for closed, nondisplaced/reduced fractures

A

Casting

125
Q

Materials needed for casting

A
  • Stockinette
  • Cast padding
  • Fiberglass or plaster casting “tape”
126
Q

Casting PEARLS

A
  • Application 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

MSK (11 decks)

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