Soft Tissue Injury Flashcards
What is soft tissue?
Articular cartilagen, tendon, ligament, fibrocartilage (i.e. meniscus, labrum), muscle
What can happed to articular cartilage?
Osteochondral defect, chondromalacia
What can happen to tendons?
Tenosynovitis, tendinopathy, tendon strain, tendon rupture
What can happen to ligament?
Sprain, tear
What can happen to Fibrocartilage?
Tear
What can happen to muscle?
Strain, cramping, contusion, myositis ossificans, compartment syndrome
Mechanisms of ligamentous injury
Repetitive stress (overuse), acute high-force injury
Ligament injury exam
Swelling, joint deformity, pain w/ palpation, ROM limited by pain (guarding), joint instability w/ stress
Joint instability tests (ACL, UCL, ATFL)
Lachman, Pivot Shift (ACL)
Milk jug sign (UCL in thumb)
Ankle Anterior Drawer (ATFL)
Valgus vs. Varus
It is determined by the distal part being more medial or lateral than it should be. Whenever the distal part is more lateral, it is called valgus. Whenever the distal part is more medial, it is called varus. Therefore, when the apex of a joint points medially, the deformity, if any, would be called valgus, as the distal part points laterally.
The L of “lateral” is also in valgus, but not in varus. When also remembering that the direction of the distal part is key: distal (more) lateral means valgus and distal (more) medial means varus.
Ottawa Ankle Rules
- Patient has pain in the malleolar zone (or under achilles)
- And any of the following: bone tenderness at the posterior edge or tip of the lateral malleolus or the medial malleolus or the inability to bear weight (four steps) immediately after injury and in the ER or physician’s office
Lateral condyle of tibia avulsion fracture on xray –>
ACL tear
Ligament Injury Tx
- Relative rest
- Immobilization (Brace, Splint, Cast)
- Rehab of surrounding structures/PT
- Surgical repair/reconstruction
Does torn ligament need surgery?
It depends! (Benefit vs risk)
Consequences of deficient ligament?
Early arthritis, secondary soft tissue injury, joint instability/disabilitiy
Surgical ligaments
–UCL thumb
–Scapholunate Ligament
–UCL elbow
–Glenohumeral*
–Coraco-clavicular
–ACL
–Tib-Fib/Syndesmosis
–ATFL
–Deltoid
–Lisfranc
Injury to tendon can involve
tendon, paratenon (more fibrous coating), tendon sheath (synovial membrane)
(or combination)
De Quervain’s Tenosynovitis
Tendon sheath swollen and inflammed as runs under extensor retinaculum (EPB and APL)
Most tendon issues are not _____ but are ______
inflammatory
Usually degenerative
Tendinopathy
Primarily degenerative (not inflammatory) - microtears
Activity-related pain (more repetitive us)
Focal tendon tenderness
Tendinopathy Treatment
Pain relief (relative rest, activity modification, bracing, ice, acetaminophen, limited oral NSAIDs, topical NSAIDs, pertitendinous steroids)
Tendon restoration (Time 3-6 months, strengthening - eccentric, pro-inflammatory injections/procedures - prolotherapy/sugar,salt into tendon - PRP/platelet rich plasma injected - autologous blood - needle tenotomy, tendon debridement surgery)
_______ strengthening most effective for tendinopathy
eccentric most effective
Tendon tearing predisposed by
Degenerative changes (age, maybe asymptomatic), malalignment, muscle imbalance, weakness, instabilty, inflexibility, glucocorticoids, fluorinated quinolones, inadequate blood supply
Tendon injury exam
- Focal Pain
- Swelling, contusion, muscle retraction/collection
- Pain provoked with active motion
•Possibly loss of active motion
- Passive motion may be limited by pain
- Special Test
Special tendon injury tests
Empty Can – Supraspinatus
Thompson’s Test – Achilles (squeeze calf –> plantarflex)
Hook Test – Distal Biceps (hook the tendon w/ finger)
Biceps supinate/pronate
supinate
*There are other flexors, but the supination will be why they need surgery
Proximal biceps tear vs distal
proximal biceps - not as big of a deal, usually long head –> popeye deformity, but short head still intact - nonsurgical
distal end - surgical
Nonoperative tendon tx
- Often spontaneously resolve (don’t usually NEED surgery)
- Time, relative rest, activity modification, immobilization
- Physical Therapy, Eccentric strengthening
- Anti-Inflammatories (pain relief) - NSAIDS, Ice, Corticosteroid injections
- Pro-Inflammatories - Prolotherapy, PRP, Autologous Blood, Needle Tenotomy
Tendon surgery - questions to ask
- Can function be recovered without surgery?
- If function is lost, will it be missed?
- Complete ruptures/full thickness tears are susceptible to muscle retraction
–Delaying surgery may make surgical procedure more difficult or impossible
–Sometimes it’s urgent
3 (important) types fibrocartilage
Glenoid labrum
Acetabular labrum
Meniscus
Function of fibrocartilage
•Load bearing
–Distributes load over broad surface area of articular cartilage
- Shock absorption
- Joint stabilization
- Possibly joint lubrication
- Loss of menisci alters the loading of articular cartilage
- May increase the probability and severity of degenerative joint disease
Fibrocartilage injury
Tramautic tears - young/active, sudden change in direction
Degenerative - aging, no specific injury, associated w/ age-related tissue changes (i.e. OA)
Fibrocartilage exam
Not very good - cannot reliably dx w/ exam
Joint inspection typically normal
Joint line palpation - pain
Pain w/ movement
Effusion not usually there (no vascularization)
Specific provacative tests for fibrocartilage
–Meniscus = McMurray’s Test
–Glenoid Labrum = Obrien’s Test, Apprehension Sign, Anterior Load and Shift Test
–Acetabular Labrum = FADIR Test/Impingement Sign
Imaging for fibrocartilage exam
Imaging important, US does not work (too far into joint)
MRI (meniscus)
MRI-arthrogram (glenoid and acetabular labrum) - contrast dye
2 important Glenoid labral tear
SLAP (superior labral): 2-10, biceps origin, athletes
Bankart (anterior inferior dislocation): 3-6
Surgically urgent fibrocartilage tear (only one)
Bucket-handle meniscus tear
Somewhat time-sensative. Loss of passive motion and inability to bear weight should raise suspicion. Limited opportunity for meniscus repair.
cartilage moves into interchondylar notch
Fibrocartilage Injury Tx
- Benign Neglect, Watchful Waiting, Symptom Monitoring (unless bucket handle)
- Repair - Vascular zone tears in young patients, Unstable flaps == Subluxates under condyle, Tear length >1/2 meniscus length
- Partial Meniscectomy
- Meniscal Transplant
Big concern w/ skeletal muscle and injury
Generate heat –> hyperthermia
Muscle strain
Powerful eccentric contraction
Injury usally at muscle-tendon junction
2 joint muscles at highest risk
strain = acute injury, immediate pain - soreness 24-48 hrs after exercise
Muscle strain prevention
- Flexibility
- Warm-up - Temperature, Extensibility
- Conditioning - Avoids fatigue
- Strength - Able to absorb more energy
Muscle Strain Tx
- Rest
- Ice
- Compression
- Elevation
- NSAIDS
- Mobilization
- Rehabilitation
Muscle cramping = cause
uncertain
dehydration
electrolyte disturbances (salty sweaters, Na, Ca, Mg)
Muscle fatigue
Most common muscle to cramp
Gastrocnemius
Medications associated given for muscle cramping
quinine sulfate (tonic water), chloroquine sulfate
Muscle contusions
- Direct trauma causing damage and partial disruption of muscle fibers
- Intramuscular hematoma frequently results
Muscle contusions treatment
•Treatment generally includes rest, ice and early return to gentle motion
Don’t usually drain hematomas (could make it worse, will usually go away on its own - unless its the playoffs lol)
Muscle contusions characterized by
•Characterized by tenderness, swelling or palpable hematoma, limits in strength/motion
Myositis ossificans
- Complication of muscle contusions – 20% of quadriceps hematomas
- Tissue calcification or ossification at the site of injury
- May be prevented with NSAIDS
- Usually seen on xray 2-4 wks after injury
- May enlarge or be symptomatic for several months before stabilizing
- Often resorbs with time
- Surgical excision can be considered later if heterotopic bone remains symptomatic
Compartment Syndrome
- Rise in intracompartmental pressure above capillary pressure
- Caused by muscle edema
- If recognized early, incising fascia can restore circulation and function of the compartmental muscles and neurovascular components
Acute compartment syndrome
- Assoc with direct trauma to bone or soft tissue
- Elevated compartmental pressure compromises tissue perfusion
Surgical emergency - fasciotomy
Chronic compartment syndrome
- Diffuse, deep pain over anterior or lateral leg after period of exercise
- Distal sensory changes often present
- Resolves with rest
- Can interrupt activity or reduce intensity of exercise
- Diagnosed by elevated compartmental pressure testing - Resting vs Exercise stress testing
Not really dangerous unless it doesn’t go away
Chronic Compartment Syndrome
•Treatment
–Relative rest, cross-training, activity modification
–Physical therapy, biomechanical correction
–Fasciotomy
Articular Cartilage
- Provides smooth surface for joint movement
- Distributes the loads of articulation
- Minimize stress on subchondral bone
- Remarkably durable and wear resistant
- Lacks nerve and blood vessels
–Isolated injury unlikely to be detected at time of injury
Articular Cartilage Injury
Acute - tear, osteochondral defect
Repetitive excessive loading - chondromalacia
ARticular cartilage injury
–Shaving – no resolution, possible worsening
–Microfracture – Arthroscopic Abrasion
–Cartilage Grafts - Autograft, Allografts – osteochondral fragment of any size, Chondrocyte – artificial matrix graft procedures
Chondromalacia
- Repetitive stress on joint
- Muscle imbalance leading to uneven wear
- Dislocation, fracture, trauma
- Pain with squatting, kneeling, prolonged sitting, running, jumping and descending stairs or hills
Chondromalacia dx
–Pain with palpation over joint
•Patellar compression test
–Pain with joint movement
–Effusion is possible
–XR – may show joint malalignment
–articular cartilage changes seen MRI or arthroscopy
Chondromalacia tx
–Ice, relative rest, acetaminophen, NSAIDS, steroid injections
–Physical Therapy – muscle balance and joint stability
Bursa
- Fluid-filled, synovial-lined sac-like structure
- Protect muscles and tendons from friction as they move over bones and other muscles
- Serve as cushion between skin and superficial bones (superficial) or muscle - bone (deep)
Causes of bursitis
•Etiology
–Direct trauma
–Prolonged pressure
–Overuse
–Crystaline Arthropathy
–Inflammatory arthritis
–Infection (septic bursitis)
Common bursitis locations
•Common Locations
–Subacromial space
–Greater Trochanter
–Olecranon
–Prepatellar/infrapatellar
–Iliopsoas
Bursitis diagnosis
- Boggy, warm, erythematous (superficial bursas)
- Tender to palpation
- Consider imaging to evaluate for local tendon tear (deep bursas)
- Consider aspiration to rule out septic bursitis, inflammatory bursitis, crystaline bursitis
Bursitis tx
- Protection
- Ice
- NSAIDs
- Steroid injection
–Concern for introduction of infection with needle
•Bursectomy
Scapholunate Dissociation
- Occurs after FOOSH
- Mid-carpal pain
- Watson’s Scaphoid Shift
- Diastasis and/or abnormal scapholunate angle on xray
- MRI arthrogram
- Casting vs repair
*** complication –> SLAC wrist (need to make diagnosis quickly) –> early arthritis and wrist fusion
FDP Rupture (Jersy Finger)
Flexor Digitorum Profundus - treat early to regain function in finger
Unhappy triad
Valgus stress -
ACL, MCL, medial meniscus
