MSK Injuries - Exam 1 Flashcards
What are the major differences between a strain and a sprain?
muscle sTrain is an injury to a muscle or muscle tendon unit
ligament sPrain is trauma to the ligaments that connect bones of a joint
Where the MC muscle strain sites? What is the MOA?
more common in muscles that attach 2 joints
aka think bigger muscles hamstrings, gastrocnemius, biceps and quads
forceful eccentric loading of a muscle
aka forced muscle-tendon unit lengthening during active contraction
Where are the MC ligament sprain injury sites? What is the MOA?
ankle, knee and wrist during sports activity
joint in overextended and the ligament is overstretched
Where are ligament sprain LESS common in children and older adults?
because these populations have weaker bones so they are more likely to avulse it or growth plate fracture
What are 9 risk factors for strain and sprains?
poor ergonomics
environment
increased age with reduced physical activity
deconditioned/unstretched muscles
specific activities
overuse
body habitus
fatigue
previous injury
When does bruising/discoloration usually appear in a strain/sprain?
usually takes around 24-48 hours to appear
What will the PE of a muscle strain look like?
+/- visible or palpable defect
pain with ACTIVE and PASSIVE FLEXION of the muscle
asymmetric swelling, tenderness and ecchymosis of injured area
What will the PE look like for a ligament sprain?
pain with active and passive ROM
joint instability/laxity: more common for higher grade sprains
+ special tests to determine which specific ligament is injuried
What is the muscle strain grading scale? What is it based on?
Grade 1-4 with 1 being the most normal and grade 4 being the worst
grade scale is based on the number of fibers affected by the injury
What does grade 1-4 muscle strain mean in detail?
What is the scale for ligament sprain grading?
How do you dx a strain/sprain? ______ is utilized if high concern for fracture
clinical suspicion: labs/imaging are NOT necessary
xray
What are the indications to get an xray for a strain/sprain?
positive “Ottawa Ankle Rule”
worsening pain/swelling with approperiate management
persistent pain/swelling after 7-10 days of appropriate management
What is the Ottawa ankle rule for ankle sprains?
What is the ottawa ankle rule for foot sprains?
_____ is utilized to confirm or grade strain/sprains. When it is indicated?
MRI
Suspected rupture or severe sprain
or
Surgical intervention is likely
What is the broad overview of strains and sprains pathophys?
phase 1: hemostasis
phase 2: inflammatory phase
phase 3: proliferative phase
phase 4: maturation phase
What is happening in phase 1 of strain/sprains pathophys? When does it occur?
occurs immediately after the injury!
platelets aggregate and release cytokines, chemokines and hormones
vasoconstriction to limited bleeding to the area
clot formation
Why does the skin temporarily blanch in phase 1?
Vasoconstriction occurs to limit bleeding into affected area
What is the associated timing for phase 2 of s/s pathophys? Describe what is happening.
immediately after the injury to 72 hours
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 (bruising) & increase in the concentration of local inflammatory mediators
What is the associated timing for phase 3? Describe what is happening
72 hours to 3 weeks
Granulation tissue is formed
Neovascularization occurs at the injury, supporting tissue healing
Inflammatory mediators are reduced
What is the associated timing for phase 4 of s/s pathophys? Describe what is happening
3 weeks to 2 years
Collagen and myofibers increase in number, strength, and organization
What are the different phases of s/s management goals? What is the associated timing?
hemostasis/inflammatory phase (day 0-3)
reparative phase (day 3- week 3)
maturation phase (week 3- 2 years)
What are the management goals for s/s depending on the day?
hemostasis/inflammatory phase (day 0-3): rest, control pain and ICE*
reparative phase (day 3- week 3): protection, pain control, full AROM, progressive muscular strength, endurance and power
maturation phase (week 3- 2 years): maintenance of ROM and flexibility, strength, endurance, power, speed and agility
What is the acrononm to help you remember what the tx is for the inflammatory phase of healing?
PRICE
Protection, Rest, ICE, Compression, Elevation
What is the ice recommendation pt education?** When is it contraindicated?
Apply for 15-20 minutes every 2-3 hours for the first 48 hours
Contraindications: Raynaud’s, PVD, impaired sensation, cold allergy/hypersensitivity, severe cold induced urticaria
______ needs to be avoided in s/s during the first phase
heat
When is surgical repair indicated for s/s? When do you need to refer?
Indicated with COMPLETE tear of muscle, tendon or ligament
Refer if joint instability, failure of conservative therapy, neurovascular compromise
_____ are first line pain management therapy in s/s
NSAIDs
What is the MOA behind 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
What are extrinsic factors that cause overuse syndrome?
repetitive mechanical load and equipment problems
What are intrinsic factors that cause 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
How will overuse syndrome present?
Pain, muscle fatigue, numbness, swelling that SLOWLY progressed over time
What is the tx for overuse syndrome?
avoid the activity that caused the problem
pain management: ice/heat, NSAIDs, injections
What are the 2 different layers of the bone anatomy?
periosteum and endosteum
Periosteum: thick outer layer that contains vessels, nerve endings and cells that repair fractures
endosteum: Inner lining of the marrow cavity
What are the 3 sections of bone in kids? Which section contains the growth plate? Which section is most susceptible to compression fracture? provides the most structural support?
diaphysis: provides the most structural support
metaphysis: most susceptible to compression fractures
epiphysis: contains growth plates
What are the 2 sections of bone in an adult?
diaphysis and metaphysis
If there is an obvious fracture, what do you need to make sure you do during PE?
ALWAYS inspect bones/joints above and below the injury!
What are the different fracture descriptions according to the Gustillo and Anderson classification?
Describe the fracture
mid- shaft diaphyseal fracture of the right tibia
distal diaphysis of the left radius and distal metaphysis of the left ulna
medial aspect of the distal tibial
metaphysis and distal 1/3 of the fibular diaphysis
define the following fracture directions? transverse
oblique
spiral
Transverse (Simple) - fx perpendicular to the shaft of the bone
Oblique - angulated fracture line
Spiral - multiplanar and complex fracture line
define the following fracture directions?
Comminuted
Segmental
Avulsed
Comminuted - fx in which there are more than two fracture fragments
Segmental - type of comminuted fx in which there are 2 fracture lines isolating a segment of bone
Avulsed - 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
What is an intra-articular fracture?
crosses the articular cartilage and enters the joint
transverse fracture, mid-shaft diaphysis of the humerus with 100% displacement
spiral fracture of the mid-shaft diaphysis of the femur
oblique fracture of the diaphysis of the proximal phalanx of the 2nd digit
segmental fracture of the tibial diaphysis
What is the difference between a nondisplaced and displaced fracture?
Nondisplaced → fragments are in anatomic alignment
Displaced → fracture is no longer in anatomic alignment
**How do you describe the degree of displacement?
Note severity in mm or % with regard to the direction the DISTAL fragment is offset in relation to the proximal fragment
**How do you describe angulation in a fracture?
Described as degree and direction of deviation of the distal fragment
What is the difference between bayoneted and distracted?
Bayoneted (Shortened): Distal fragment longitudinally overlaps the proximal fragment in mm/cm
distracted: Distal fragment is separated from the proximal fragment by a gap
in mm/cm
What is rotational deformity? How is it detected?
Degree the distal fragment is twisted on axis of normal bone
Usually detected by physical exam
100% displaced transverse diaphysis humeral with 30% medial angulation`
25% ventral displacement without angulation with shortening
femur transverse 100% displacement diaphysis
transverse fracture of the mid-shaft diaphysis femur. 100% medial displacement with shortening. No angulation
diaphysis radial 100% displacement with 35 medial angulation
oblique fracture of the distal 1/3 diaphysis of the radius. 100% lateral displacement with shortening and 30 degree ventral angulation
comminuted tibial fracture at the mid-diaphysis. 100% medial displacement and without angulation. Oblique fibular fracture at mid-diaphysis. 100% medial displacement with approx 10 degree medial angulation
What is a torus fracture? What is another name for it?
An incomplete fracture along the distal metaphysis where the bone is most spongy
buckle fracture
Where is the MC place to have a buckle fracture? What is important to note?
distal radius
need to look at multiple views!!
What is a greenstick fracture? what is it usually due to?
A fracture that doesn’t extend through the entire periosteum
Occurs in the pediatric population due to soft bone
When is the salter-harris classification system used?
Used to describe fractures involving the growth plate
When does the average females pt’s growth plates close? male?
female 12-14 years old
male 14-16 years old
If you are concerned about a Salter-Harris fracture, what should you do?
need to order xray of the UNAFFECTED side because it can be helpful to detect fractures in skeletally immature children
What are the 5 different types of salter- harris classifications? Which one is the MC?
type 2
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)
What SH classification?
type 1
What SH classification?
type 4
What SH classification?
type 3
What SH classification?
type 2
What are the 3 phases of fracture healing?
stage 1: inflammatory phase
stage 2: reparative phase
stage 3: remodeling phase
What is happening in stage 1 of fracture healing?
bleeding from the fx site and surrounding tissue
peaks after several days and bioactive cells migrate to fx site hematoma and leads to formation of granulation tissue
What is happening in stage 2 of fx healing?
neovascularization promotes healing
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
What is stage 3 of fracture healing? When does it typically occur?
Overlaps with repair phase and can continue for several months
Woven (immature) bone is replaced with more mature lamellar bone
around 6-10 weeks
What are indications for an IMMEDIATE orthopedic consultation?
Open, displaced, unstable or irreducible fractures
Fractures complicated by compartment syndrome, nerve, or vascular injury
closed fracture management is regulated by what 4 factors?
bone involved
type of fracture
degree of displacement
open vs closed fx
what 3 bones are considered more emergent automatically? What is the initial tx?
hip, pelvis and spine
bed rest and NON-weight bearing
______ if done if the fx is displaced or angulated. What is severe?
reduction
will require sx.
Open reduction and internal fixation (ORIF) with plates, screws, pins or intramedullary devices
What is the tx for an open fx?
EMERGENCY!!!
Require irrigation/debridement followed by application of sterile dressing
NPO
Pain medication
IV abx
Why is an open fx considered an ortho emergency?
High risk of osteomyelitis, compartment syndrome and neurovascular injury
open type I and II fx, what abx?
Type I and II Fracture - 1st gen ceph: Cefazolin (Ancef) 1 g every 6-12h
open type III fx, what abx? What do you give if concern for anaerobic infection?
1st gen ceph + Aminoglycoside (gentamicin)
add metronidazole
what 6 factors make the fx prognosis worse?
Skeletal maturity
Fractures of multiple bones in the extremity
Intra-articular fractures
Marked displacement of fractures
Unstable vertebral fractures
Comminuted, oblique and segmental fractures
What is malunion? What are the typical underlying causes? What is the tx?
Inadequate alignment of a fracture
Results from inappropriate reduction, immobilization or surgical error in alignment
Osteotomy or bone cuts to restore anatomical alignment
What is considered a nonunion? What is the tx?
Lack of healing within 6 months of an injury
or
No healing progress in 3 consecutive months
Surgical fixation, bone graft, electrical/US stimulation
What are 6 factors that affect healing?
Smoking
indolent infection
inadequate immobilization
malnutrition
NSAID use significant
soft tissue injury
What are stress fx risk factors?
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
T/F: Stress fractures are easily seen on xray
FALSE!! stress fractures may not appear on xray for several weeks
If suspicion is high and diagnosis needs confirmed, proceed with MRI, CT or bone scan
What bones involves would be considered a low-risk stress fracture?
Fx of the 2nd-4th metatarsal shafts
Posteromedial tibial shaft
Fibula
Proximal humerus or humeral shaft
Ribs, sacrum and pubic rami
What bones involved are considered 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
What are the 4 goals of splinting?
reduce pain, bleeding and swelling around the injury
immobilize the injury
prevent further damage of muscles, nerves and blood supply
prevent further laceration of skin and contamination of an open wound
_____ and _____ splints are the preferred splint of choice when a splint is expected to remain in place for more than a few hours
plaster
fiberglass
When is the optimal timing post injury for cast placement?
once the swelling has resolved, usually 5-7 days
