Musculoskeletal injuries 3 Flashcards
SCI: Definitive management
Closed reduction- Halo traction
Surgical reduction
- Early management dèbrides bone fragments
- Late management fuses fractured vertebrae permanently
Miami J Collar- For suspected or proven stable cervical spine fracture
Spondylolisthesis (definition)
Slippage of one vertebral body over another (usually L5/S1). Usually happens so gradually that pain is just the symptom
Spondylolysis (definition)
Defect of pars interarticularis. Can lead to instability and nerve compression.
Spondylitis
Inflammation of the vertebrae, ankylosing spondylitis is the most common cause, common in patients with positive rheumatoid factors
Spondylolisthesis: S/Sx; Tx
5 types, 4 grades.
S/sx: back pain, tight hammies, lordosis/kyphosis. Gait issues. Can have neuro sx.
Tx: Usually start with NSAIDs, braces, exercises.
Spondylolysis: S/Sx; Tx
Have a defect in the pars interarticularis of the neural arch, that portion of the neural arch that connects the superior and inferior articular facets.
S/Sx: Can be asymptomatic, usually occurs in young patients, back pain with activity.
Tx: brace, PT, rest
Ankylosing spondylitis (AS): MOI; S/Sx
Autoimmune Dz. Most Pts express HLA-B27 gene
S/Sx: back pain, limb pain. Often w/ eye Sx. Pain worse at rest, better with activity. “Bamboo spine.”
Cauda Equina and Conus Medullaris Syndromes: Etiology
Chronic or acute compression of the cauda equina or the conus medullaris.
The most common causes of cauda equina and conus medullaris syndromes are the following:
- Lumbar stenosis (multilevel)
- Spinal trauma including fractures
- Herniated nucleus pulposus (cause of 2-6% of cases of cauda equina syndrome)
- Neoplasm, including metastases, astrocytoma, neurofibroma, and meningioma; 20% of all spinal tumors affect this area
- Spinal infection/abscess (eg, tuberculosis, herpes simplex virus, meningitis, meningovascular syphilis, cytomegalovirus, schistosomiasis)
Cauda Equina and Conus Medullaris Syndromes: S/Sx
Low back pain
Pain radiating into the legs
Motor weakness (important to differentiate weakness from pain causing difficulty moving)
Perineal anesthesia or “saddle anesthesia”
Bladder/bowel incontinence
Loss of sphincter tone
Cauda Equina and Conus Medullaris Syndromes: Imaging
If suspected, an MRI is required emergently to determine its presence or absence (will not be visible on CT)
Cauda Equina and Conus Medullaris Syndromes: Tx
If suspected, give dexamethasone 10mg IV
Emergent neurosurgery evaluation for possible decompression surgery
Ribs: Gross anatomy
12 pairs of ribs
First 7 articulate with spine/sternum (true ribs b/c they connect to the sternum & manubrium directly)
8-10 articulate anteriorly with costal cartilage (ie false ribs)
11 – 12 are “floating” in that they don’t articulate anteriorly
Inferior to each rib is the neurovascular bundle: nerve, artery, vein
Rib injuries: MOI
Injury can occur from all things blunt, or sometimes even from coughing or sneezing too forcefully; rarely there are pathological fractures, from a lytic or blastic lesion
Rib contusion
Relative common, from a blunt traum
Rib fracture
Most common at the postern-lateral bend of the rib (weakest point structurally)
Sternal fracture
- Rare
- Complicated occasionally by pericardial injury
Rib injuries: Assessment (5 points)
- Consider the location of the pain, so as to suggest likelihood (or lack thereof) of injury to the underlying organs
- Liver, splenic injuries
- Pneumothorax - Flail: 3 or more ribs, 2 or more places
- Pain often localized to area of Fx
- Splinting, auscultatory crepitance
- Pleuritic pain
Rib injuries: Imaging
PA/Lateral chest xray: Usually adequate and helps identify PTX, pulm contusion and wide mediastinum
Dedicated rib series: Use a bone window and allows for better visualization. *Usually not used unless can’t visualize on PA/Lat or when multiple fxs present
CT scan: Definitive
Rib injuries: Tx
Single, non-displaced: NSAIDs, spirometry Opioids should be used with caution Epidural, intercostal nerve blocks in severe cases Expected recovery is about 8 wks
Rib injuries: Hospital admission
Admit if 3 or more fractures, or those with a flail segment
Admit to the ICU if 6 or more fractures or elderly w/ 3 or more fxs
Shoulder: Gross anatomy
- Clavicle
- Scapula
3. Proximal humerus Four articular surfaces a) sternoclavicular b) acromioclavicular c) glenohumeral d) scapulothoracic
- Labrum, rotator cuff
Shoulder injuries: Common anterolateral pain
Rotator cuff tendinopathy (overuse): Pain with reaching over head
Rotator cuff tear (trauma): Pain with reaching over head associated with weakness
AC joint separation (blunt trauma): Pain with reaching over head; pain with reaching down to pick something up off the ground; seformity, easily seen on x-ray
Shoulder injuries: Common posterior pain
Posterior rotator injury
Referred from cervical spine
Shoulder injuries: Poorly localized pain
It suggests a sprain
*Poorly localized can be intraabdominal, cardiac, depression, or C-spine
Shoulder fxs: Locations
Humeral head
Glenoid (rare)
Clavicle
Scapula (look for other injuries, require high energy)
Shoulder dislocations: Types
Anterior
Posterior (rare)
Inferior (very rare)
Shoulder injuries: Physical exams
Inspection- Deformity, erythema, swelling (septic joint, reactive arthritis)
Neurovascular assessment
ROM, Strength
Shoulder injuries: Imaging
Plain films, assess for fracture/dislocation only
MRI can assess for soft tissue injury
Shoulder injuries: Apley scratch test
Apley scratch test- requires abduction and lateral rotation of one shoulder and adduction and medial rotation of the other shoulder. Tests overall ROM. Again, requires intact glenohumeral joint and rotator cuffs.
Positive can be RC injury, arthritis, capsulitis
Subacromial bursitis: Background
An inflammatory condition of the subacromial bursa
Subacromial bursitis: S/Sx
Sharp pain, often of fairly rapid onset
Subacromial bursitis: Physical exam
Patients often exhibit tenderness over the greater tuberosity. Difficulty in abduction may occur, specifically from 70° to 100°.
Subacromial bursitis: Tx
NSAIDs and rest
Jobe’s supraspinatus test
- Assesses supraspinatus muscle
- Pain suggests suprasinpatus tendinopathy
- Weakness suggests supraspinatus muscle tear (posterior rotator cuff tear)
- The examiner applies resistance against the patient trying to abduct the shoulder
Infraspinatus test
- The examiner applies resistance to the patient external rotation
- Pain or weakness with external rotation of the shoulder suggests an isolated injury to the infraspinatus muscle
Speed’s test
- Assess biceps tendon injuries
- Pt forward flexes the shoulder about 30 degrees against the clinician’s resistance while keeping the elbow fully extended and the arm fully supinated
Yergason’s test
- Assess biceps tendon injuries
- Pt holds her arm adducted w/ the elbow flexed to 90 degrees and the arm fully pronated. While they hold hands, the Pt attempts to supinate while the examiner resist
Rotator cuff injuries: Common injury, MOI, S/Sx, Assessment, Tx
- Supraspinatus most common
- MOI: throwing, overhead work
- S/Sx: Worse pain at night, reaching overhead
- Assessment: Shoulder exam, imaging
- Treatment: Ice, NSAIDs, ortho referral
- Usually only certain people require repair
- Tendinopathies will usually heal
Biceps tendon injuries: Characteristics, Assessment, Tx
Characteristics: Anterolateral pain
Pain at bicipital groove
Assessment: Yergason’s test; Tendon rupture will create the “Popeye sign”
Tx: Ice, NSAIDs, PT, Ortho referral
* Full rupture or tear will occasionally need repair
Biceps tendinitis (definition)
Inflammation of the tendon around the long head of the biceps muscle.
Biceps tendinosis (definition)
Caused by degeneration of the tendon from athletics requiring overhead motion or from the normal aging process
Clavicular fx (middle third): Characteristics, MOI, Tx
Most common and least worrisome
MOI: blunt trauma to the clavicle, or a fall onto the lateral aspect of the shoulder
Always consult orthopedics: open fracture, neurovascular comp.
Treatment: sling, ice, NSAIDs
Activity: as tolerated
Healing time: 6 – 12 weeks
Orthopedics follow up: 2 weeks, repeat films
Clavicular fx (distal third): Characteristics, Tx
More concerning because it often involves the AC joint
Always refer
Treatment: Arm sling
Activity: Immobile until after ortho follow up
Healing time: 6 – 12 weeks
Follow up: 2 weeks, repeat films
Clavicular fx (medial third): Characteristics, Tx
- Very worrisome because it affects the connection between the shoulder and the trunk
- Referral: All
- Treatment: Arm sling
- Activity: Immobile until orthopedics follow up
- Healing time: 6-8 weeks
- Follow up: Close follow up with serial X-rays
Scapular fx: MOI, Assessment, Imaging, Tx
- Very concerning
- MOI: Fall onto the scapula directly, other traumatic processes
- Exam: Pain over Fx site, patient will usually hold arm in adduction
- Imaging: Plain films, CT
If other injuries are encountered, often this fracture becomes an issue of least concern - Tx: A sling if an isolated injury
Humeral head fx: MOI, Assessment, Imaging, Tx
MOI: Fall on outstretched hand (FOOSH)
Exam: Diffuse shoulder pain swelling, ecchymoses
Imaging: X-rays
Treatment: Sling/swathe, Hand ROM exercises
Often heal well without surgery, even with non-union
*Since these often occur in the elderly, particular issues exist if the patient uses a walker or cane, or if this is the dominant arm
Shoulder dislocation: MOI, Assessment, Imaging, Tx
MOI: Generally by a trauma with the shoulder in abduction, occasionally recurrent
Exam: Deformity noted, plus a depression at the AC joint, the patient cannot move the shoulder at all, or will not be able to use the arm
- Assure neurovascular integrity
- Specifically assess sensation over the deltoid
Tx: Prior to reduction, check X-rays to rule out fractures
Check post reduction X-rays, reassess neurovascular integrity
- Sling for up to 4 weeks
- Refer to orthopedics
Two techniques for shoulder reduction
- Cunningham technique- This technique does not require anesthesia. Tell a Pt to touch his forehead to test if the shoulder is reduced properly.
- Milch technique- This requires a little bit of sedation
Elbow injury types
Lateral pain: lateral epicondylitis (tennis elbow).
Medial pain: medial epicondylitis (golfer’s elbow)
Elbow swelling: Bursitis, septic joint
Fractures: Radial head, radial neck, olecranon, distal humerus
Dislocations
Epicondylitis: S/Sx, Assessment, Tx
aka Tennis elbow
S/Sx: Pain medially/laterally over condyle; Pain with handshaking, grasping, rotation
Assessment: Tenderness to palpation of condyles with elbow flexed; ROM should be intact, no effusion
Treatment: Stop doing the thing that caused it; Rest, Ice, NSAIDs, referral
Olecranon bursitis: S/Sx, Assessment, MOI, Tx
S/Sx: Swelling, erythema over olecranon bursa, appears as a “golf ball” over the olecranon
Assessment: ROM usually intact
MOI: trauma, infection, RA, sepsis, gout
Tx: Aspiration (complete aspiration is usually not helpful), compression, elevation, warm compresses
If infection suspected, cover for MRSA: Bactrim (outpatient) Vancomycin (inpatient)
*Joint effusion uncommon, but aspiration of the bursa can be performed, if >2000 WBC/hpf is usually suggestive of infection
Radial head fx: MOI, Assessment, Imaging
MOI: Fall on outstretched hand
Exam: Pain laterally, held in 800 flexion for comfort
Pain in the elbow with supination/pronation
Radial nerve exam: extend thumb/wrist
Imaging: AP, Lateral
Occasionally, no fracture is visible, but a “sail sign” is seen on xray, indicating likely occult fracture
Radial head fx: Types & Tx for each type
Type 1 : < 2 mm displaced Sling, ice, analgesia, ROM Type 2: > 2 mm displaced Sling vs. ORIF Type 3: Comminuted ORIF
Elbow dislocation: MOI, Assessment,
MOI: Fall on outstretched hand, usually with the arm abducted Is almost always posteriorly dislocated Often associated with fractures Neurovascular compromise frequent! Exam: elbow flexed, olecranon deformity
Elbow dislocation: Imaging, Tx
Check X-rays before any attempt at reduction Closed reduction can be attempted, usually sedation is necessary, consult orthopedics as these can be more challenging than they seem Post reduction: X-rays Reassess nerve/artery Posterior splint Sling Close orthopedics followup
