Soft tissue injuries profoma Flashcards
Management for soft tissue injuries
- Analgesia e.g. NSAIDs or steroids
- RICE
- Immobilisation - e.g. splint, sling, brace
- Physiotherapy
- Surgical repair e.g. meniscal resection
Where can soft tissue injuries occur?
- skin
- meniscal injury
- blood vessels
- tendons
- ligaments
- pain caused by lymph
- bursa- bursitis
- nerve pain
- fascia
- fat
- joint capsule
- muscle
What are the types of skin injury?
- Celluitis - infection of skin caused by staph or strep
- Bruise, Bite, Burn
- Haemosiderin - product of iron seen in varicous veins = discolouration of leg (brown colour around ankles)
- Rashes
- Ulcers - any break in the epithelial lining of the skin
- Nails e.g. ingrown toe-nail
What is cellulitis?
- Bacterial soft tissue infection - most commonly staph. aureus.
- Needs antibiotics & monitoring.
- Differential for Gout & Necrotising faciitis
What are Baker’s cyst?
- Caused by extra fluid
- It goes to the part of the knee that has least resistance.
- feels tight
- Ruptured Baker’s cyst can lead to extensive bleeding & bruising which can then travel down the compartment of leg.
- Differential to ruptured Baker’s cyst is DVT
Meniscal injuries: what are the menisci?
- The menisci are two semicircular fibrocartilage structures.
- Lie between femoral & tibial articular surfaces- lateral & medial menisci
- Act as shock absorbers
NOTE: view note for diagram
Aetiology of meniscal injury
- Traumatic - twisting or landing w/ knee flexed. Can be associated w/ ligament tear.
- Degenerative- occurs in older pop due to abnormal cartilage.
Types of meniscal tears/ injuries:
- Bucket handle tear
- Radial
- Horizontal cleavage
- Flap or parrot break
- Meniscal cyst- results from synovial fluid entering meniscal tear- a valve effect means fluid in cysts cannot drain back into knee
Clinically important to establish how peripheral a tear is.
- Very peripheral tears occur through vascular tissue = good to repair, as these tears can heal.
- Meniscal tears further away from the blood supply (i.e. further into the knee) cannot heal.
NOTE: view notes for diagram
Presentation of meniscal injuries
- Playing sport
- Popping sensation felt
- Locking or giving way
- Joint line tenderness
- Swelling over 24 hours
- Effusion - but large effusions should raise suspicion of ligament injury or fracture.
- Meniscal cyst - palpable on joint line.
- Acute painful locked knee ORgradual chronic nagging pain w/ associated swelling over months or years.
Investigations for meniscal injuries
- X-ray - exclude fracture and OA
- MRI - confirms prescence of torn menisci
- Arthroscopy of knee
Leg pain caused by blood vessels
Varicose veins - caused by leaky valves in veins so blood pools.
Thrombothrovitis- enflamed veins
Deep vein thrombosis - blockage - key side effect of orthopaedic surgery.
Aneurysm - wall of artery thins & weakens can rupture.
- results in loss of pulse
- area becomes very pale
Peripheral vascular disease - lack of blood flow through muscle = ischaemia (usually presents when walking).
Leg ulcers - constant high pressure in veins can damage the blood vessels leading to skin easily breaking after a knock.
Blood vessels: deep vein thrombosis- what is it? presentation, treatment, investigations, risk factors?
Occurs when blood clot forms deep inside part of body e.g. legs, arm
- can be life threatening- pulmonary embolism
Risk factors:
- Orthopaedic patients- post surgery
- Bed bound
- Reduced mobility
- prolonged flights
- family history
Presentation
- Unilateral
- Pain
- Swollen - due to blood retention.
- Different colour - because there is more venous blood in the leg (slightly red/purple).
- cramping on affected leg
Diagnosis
- Wells score
- bloods
- thrombophilia screen.
Treatments:
- warfarin
- DDOAC
- Stocking
Tendons- tendinopathy: what is it, clinical presentations, investigations & management
Injury or strain to tendon
- usually degenerative
Clinical features:
- Tenderness
- Pain on movement especially against resistance
- Soft tissue swelling (not always present)
- Common in shoulder, elbow (Tennis or golfers elbow) & achilles tendon.
Investigations:
- Ultrasound (to show degree of tendon damage)
- X ray - to rule out arthritis
- MRI - if symptoms related to neck.
- EMG - to rule out nerve compression.
Mangement:
- RICE
- Splinting
- NSAID
- Corticosteroid
- Surgical: Mini-open muscle resection under local anaesthesia or Fascial elevation & tendon origin resection
Tendinopathy: examples of conditions?
- Rotator Cuff
- Beneath the acromion is the subacromial space.
- If space becomes narrowed, irritation of supraspinatus can occur giving rise to tendinopathy. - Lateral epicondylitis- tennis elbow
- Chronic degeneration of tendon.
- Most commonly affected muscle is extensor carpi radialis brevis.
Presentation:
- common in dominant arm
- pain in lateral elbow
- pain w/ wrist extension
- reduced grip strength
Clinical examination:
- Cozen’s test - resisted wrist extension.
- Coffee cup test - rating pain while picking up full cup.
- Pain on supination
- Medial epicondylitis- golfer’s elbow:
- Tendon overload injury
- Flexor-pronator
- Flexor carpi radialis brevis
- Due to repetitive forced wrist extension & forearm supination
Presentation:
- Might experience pain on the ulnar side of forearm, wrist & fingers.
- Tenderness over medial epicondyle
- Swelling or erythema
- Stiffness of elbow
- Weakness in hand & wrist
- Parasthesia in ring & little finger.
- Weakness of hand grip
Clinical examination:
- Resisted wrist flexion while elbow is extended & forearm is supinated
- Maximal grip strength
Tendons- tenosynovitis: what is it? Clinical features? Management?
Inflammation of synovial lining of a tendon sheath
- Caused by inflammatory arthritis or trauma.
- Usually a repetitive or unaccustomed movement.
Clinical features:
- Localised pain
- Swollen and tender
- Crepitus felt on palpation
- In hand = grip difficulties
Management:
- Rest
- Splinting
- Local corticosteroid Injection
- Surgical decompression of tendon sheath
Tenosynovitis: examples of conditions?
- de Quervains tenosynovitis
- Inflammation of synovial lining of tendon sheath.
- Extensor pollicis brevis & abductor pollicis longus tendons.
examination:
- Finkelstein test- place them in closed fist & told hand down- pain felt during tests is positive for condition
- Trigger finger:
- Tenosynovitis of the flexor tendons of fingers
- A nodule can develop on the tendon in response to constriction of the tenon sheath.
- Nodule catches on the flexor tendon pulleys
- Finger may be held in flexion.
Tendons-rupture: what is it, presentation, investigation, management?
What is it?
- Chronic inflammation e.g. in RA
- Degeneration
- Trauma
Clinical features
- Loss of movement
- Deformity
- Swelling (sometimes)
- Commonly Achilles’ or patella tendon
Investigation
- Ultrasound or MRI for confirmation
Management
- Analgesia
- Sling or splint
- Surgical reconstruction (within 4-5 weeks) - involves tendon repair or transfer. Do this if loss of function occurs.
Tendon rupture: examples of conditions?
- Achilles tendon rupture
Risk factor:
- Sports
- Aging
- Male
- Increased BMI
- Smoking
- Peripheral vascular disease
- Diabetes
Clinical examination:
- Could be partial or complete rupture.
- Dip test - ask to kneel on chair & feel the back of the heel (compare both sides) - if there is a dip, the rupture is complete.
- Squeeze test-plantar flexion occurs when you squeeze the calf (foot points down) - if this doesn’t occur, the tendon is ruptured.
Management
- Conservative: walking boot or cast
- Cast: in plantar flexion so torn ends of tendon proximate & heal in this position
- Boot: (for around 3 months) and weight bearing = similar outcome to cast.
- Surgical repair
- Distal biceps tendon rupture
Risk factors
- Usually men in 40s-50s
- Common in anabolic steroid users
- Weight-lifting any sort of load
Presentation
- Popeye sign - muscle bulge in upper arm.
- High index of suspicion! Very easy to miss. If in doubt get a MRI scan or Ultrasound.
Examination:
- Hook test: poke finger into distal biceps tendon, if you can’t it is ruptured
- Might struggle to supinate against resistance
- Mallet finger
- Extensor tendon rupture of distal phalanx
- Results in Flexion of DIP joint
- Inability to extend DIP joint - Patellar tendon
Tendons: what is enthesitis?
inflammation of the
entheses, the sites
where tendons or
ligaments insert into
the bone.
Ligaments- ACL tear: presentation, clinical examination, investigation, management
Aetiology:
- damage from twisting injury
Presentation
- Pain
- Swelling (due to lots of bleeding) - w/in minutes to hours (unlike menisci).
- Frequently report being able to run in a straight line but not being able to twist & turn
- symptoms of instability.
- Giving way is pain free
- Tense effusion after acute injury.
- Usually fit, well & young
Clinical examination:
- Anterior draw test
- Lachman test - better than anterior draw test- takes out opposition of hamstring out of play. Stabalise femur & apply anterior force to tibia
Investigation:
- X-rays will usually be normal
- Loss of black line on MRI
NOTE: view notes for MRI image
Management:
- Conservative: in analgesia, brace & physio.
- Surgical reconstruction & education
Ligaments: PCL- aetiology, presentation, Examination, investigation and management?
Aetiology:
- Rare
- Sporting injuries
- Car accidents e.g. dashboard injury
Presentation:
- Pain
- Unable to weight bear
- Swelling less obvious than ACL injury
- Complain less of instability than ACL injuries.
- Posterior sag
Examination:
Posterior draw test:
- Usually occurs in combo w/ other ligament injuries - associated w/ lateral collateral injury.
- Important to check distal vasculature as knee may have been dislocated.
- Rarely, may injury popliteal artery.
Investigation
- MRI
Mangement:
- Isolated PCL injuries - rehabilitation, physio, RICE.
- Combined injuries or symptomatic instability - reconstruction surgery.
Ligaments- Collateral cruciate ligaments: aetiology, presentation, examination & management
Aetiology
- valgus strain or skiing- for medial ligament
- isolated injury uncommon in lateral ligament
- results in anterior cruciate ligament & medical collateral ligament rupture
Presentation
- Sport
- No effusion of isolated tear (because they are extra-articular).
- Pain & possibly instability
Examination:
- Varus & valgus stress test
Management:
- Analgesia
- Physio
- Bracing for 6 weeks
- Surgery sometimes needed for chronic unstable injuries.
Ligaments- ankle strain: aetiology, presentation, investigation & management
Aetiology:
- Sports injury common
- Inversion = lateral ligaments (anterior talofibular and calcaneofibular ligaments) damaged.
- Eversion = medial ligament (deltoid ligament) damaged.
- Damage to lateral more common.
NOTE: view notes for image of ligaments
Presentation:
- Pain & feel something go
- Swelling occurs rapidly
- Ankle instability & joint giving way.
Investigation:
- X-ray only performed if there is bony tenderness or inability to weight bear.
- Ottawa ankle rules!
Ottawa rules:
- ankle x -ray required if there is any pain in malleolar zone alongside:
- bone tenderness at either posterior edge or tip of of lateral, base of fifth metatarsal & navicular
- as well as inability to weight bear on both feet
Management:
- Analgesia
- RICE
- Physio
- Surgery rarely required
Pain caused by lymph?
Drains fluid from tissues
Surgery e.g. breast cancer can distrupt the normal flow of lymph = develop swelling (lymphodema)
What is a bursa?
Lined w/ epithelium
produces synovial fluid- small sacs of synovial fluid
Point where muscles & tendons slide across bone
reduces friction & trauma
What are common locations for bursitis?
Bursitis= inflammation of bursa
Trochanteric bursitis- pain over lateral aspect of hip
- pain on direct pressure- lying on it
Prepatellar bursitis- housemaids knee
- swelling at front of knee
- good ROM
- Sore to press
Olecranon bursitis, “student’s elbow”, characterised by pain & swelling in the elbow
Subacromial bursitis, giving shoulder pain, is the most common form of bursitis.
- bursa acts as cushion to allow supraspinatus tendon to slide smoothly over tissue & bone
Achilles bursitis
Retrocalcaneal bursitis
More common in women- shorter legs then men & pelvis is wider
Pain is felts over greater trochanter & radiates down leg
- keeps them up at night
What are some causes of muscle pain?
- Overuse
- Viral infections e.g. flue
- cramp
- claudication
- muscle rupture or tear e.g. hamstrings
- compartment syndrome
- chronic pain e.g. fibromyalgia etc- next week LOs
- Hypothyroidism
What are causes of nerve pain?
Referred pain- sciatica - sciatic nerve being compressed.
Peripheral neuropathy - damage caused by toxins or short of vits e.g. B12 or folate.
Entrapment e.g. meralgia paraesthica complain of burning on the leg.
Compression e.g. carpel tunnel sundrome
What are causes of fascia pain?
- Plantar facitis
- Inflammation of the plantar fascia- ligament that connects heel of feet to front of feet & stabilises arch of feet
- Pain on heel & under arch
- due to repetitive high load activities
- pain on first steps when getting out of bed in morning - Necrotising fascitis:
- Bacterial infection that affects tissue beneath skin & surrounding muscles & organs (fascia).
- Sometimes called “flesh-eating disease”, although the bacteria that cause it do not “eat” flesh, but release toxins that damage nearby tissue. - Compartment syndrome
What are causes of joint capsule pain?
- Synovitis
- Frozen shoulder (adhesive capsulitis) - inflammation of the joint capsule causing it to tighten = restriction of movement. Diabetes is a risk factor for this.
What is lymphodema? Causes? Symptoms? Treatment?
Swelling due to build-up of lymph fluid in the body.
- Lymph nodes act like a drain in your sink- if drain is clogged, the fluid cannot drain.
Causes:
- cancer treatments that remove or damage your lymph nodes
- cancer enlarging and blocking lymph vessels
surgery- if lymph nodes are removed
- parasites- common in developing country
- inherited
Symptoms:
- Swelling of part or all of the arm or leg, including fingers or toes
- A feeling of heaviness or tightness
- Restricted range of motion
- Recurring infections
- Hardening & thickening of the skin (fibrosis)
- unilateral
No treatment but can try:
- compression bandages & garments- encourages lymph fluid to flow back toward the trunk of the body.
- exercise
