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Musculoskeletal injuries 3 Flashcards

1
Q

SCI: Definitive management

A

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

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2
Q

Spondylolisthesis (definition)

A

Slippage of one vertebral body over another (usually L5/S1). Usually happens so gradually that pain is just the symptom

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3
Q

Spondylolysis (definition)

A

Defect of pars interarticularis. Can lead to instability and nerve compression.

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4
Q

Spondylitis

A

Inflammation of the vertebrae, ankylosing spondylitis is the most common cause, common in patients with positive rheumatoid factors

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5
Q

Spondylolisthesis: S/Sx; Tx

A

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.

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6
Q

Spondylolysis: S/Sx; Tx

A

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

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7
Q

Ankylosing spondylitis (AS): MOI; S/Sx

A

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.”

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8
Q

Cauda Equina and Conus Medullaris Syndromes: Etiology

A

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)

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9
Q

Cauda Equina and Conus Medullaris Syndromes: S/Sx

A

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

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10
Q

Cauda Equina and Conus Medullaris Syndromes: Imaging

A

If suspected, an MRI is required emergently to determine its presence or absence (will not be visible on CT)

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11
Q

Cauda Equina and Conus Medullaris Syndromes: Tx

A

If suspected, give dexamethasone 10mg IV

Emergent neurosurgery evaluation for possible decompression surgery

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12
Q

Ribs: Gross anatomy

A

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

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13
Q

Rib injuries: MOI

A

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

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14
Q

Rib contusion

A

Relative common, from a blunt traum

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15
Q

Rib fracture

A

Most common at the postern-lateral bend of the rib (weakest point structurally)

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16
Q

Sternal fracture

A
  • Rare

- Complicated occasionally by pericardial injury

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17
Q

Rib injuries: Assessment (5 points)

A
  1. Consider the location of the pain, so as to suggest likelihood (or lack thereof) of injury to the underlying organs
    - Liver, splenic injuries
    - Pneumothorax
  2. Flail: 3 or more ribs, 2 or more places
  3. Pain often localized to area of Fx
  4. Splinting, auscultatory crepitance
  5. Pleuritic pain
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18
Q

Rib injuries: Imaging

A

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

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19
Q

Rib injuries: Tx

A 
Single, non-displaced: 
NSAIDs, spirometry
Opioids should be used with caution
Epidural, intercostal nerve blocks in severe cases
Expected recovery is about 8 wks
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20
Q

Rib injuries: Hospital admission

A

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

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21
Q

Shoulder: Gross anatomy

A
  1. Clavicle
  2. Scapula
3. Proximal humerus
Four articular surfaces
a) sternoclavicular
b) acromioclavicular
c) glenohumeral
d) scapulothoracic
  1. Labrum, rotator cuff
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22
Q

Shoulder injuries: Common anterolateral pain

A

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

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23
Q

Shoulder injuries: Common posterior pain

A

Posterior rotator injury

Referred from cervical spine

24
Q

Shoulder injuries: Poorly localized pain

A

It suggests a sprain

*Poorly localized can be intraabdominal, cardiac, depression, or C-spine

25
Shoulder fxs: Locations
Humeral head Glenoid (rare) Clavicle Scapula (look for other injuries, require high energy)
26
Shoulder dislocations: Types
Anterior Posterior (rare) Inferior (very rare)
27
Shoulder injuries: Physical exams
Inspection- Deformity, erythema, swelling (septic joint, reactive arthritis) Neurovascular assessment ROM, Strength
28
Shoulder injuries: Imaging
Plain films, assess for fracture/dislocation only | MRI can assess for soft tissue injury
29
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
30
Subacromial bursitis: Background
An inflammatory condition of the subacromial bursa
31
Subacromial bursitis: S/Sx
Sharp pain, often of fairly rapid onset
32
Subacromial bursitis: Physical exam
Patients often exhibit tenderness over the greater tuberosity. Difficulty in abduction may occur, specifically from 70° to 100°.
33
Subacromial bursitis: Tx
NSAIDs and rest
34
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
35
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
36
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
37
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
38
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
39
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
40
Biceps tendinitis (definition)
Inflammation of the tendon around the long head of the biceps muscle.
41
Biceps tendinosis (definition)
Caused by degeneration of the tendon from athletics requiring overhead motion or from the normal aging process
42
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
43
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
44
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
45
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
46
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
47
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
48
Two techniques for shoulder reduction
1. Cunningham technique- This technique does not require anesthesia. Tell a Pt to touch his forehead to test if the shoulder is reduced properly. 2. Milch technique- This requires a little bit of sedation
49
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
50
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
51
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
52
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
53
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 ```
54
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 ```
55
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 ```

AGACNP (21 decks)

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