MSK Injuries Flashcards
(130 cards)
1
Q
MSK injuries fall into what categories?
A
- Direct (contact) or indirect (non-contact)
- Muscle strain
- Ligamentous sprain
- Fracture
- Contusion/hematoma
2
Q
Keys to approaching MSK injuries
A
- Rule out emergency
- Rule out fracture
- Manage conservatively
3
Q
What is a muscle strain?
A
- Pulled muscle
- Injury involving the muscle or muscle-tendon unit
4
Q
Where is a muscle strain mc?
A
- distal muscle tendon junction injury
- In muscles attached to 2 joints
5
Q
MOA causing muscle strain
A
Forceful eccentric loading of the muscle
6
Q
What is a ligament sprain?
A
Trauma to the ligaments that connect bones of a joint
7
Q
Where are the most common ligament sprains?
A
- Ankle
- Knee
- Wrist during sports activities
8
Q
MOA of ligament sprain
A
Joint overextended; ligament overstretched
9
Q
Ligament sprains are uncommon in children and older adults. Why?
A
Children and older adults tend to have weaker bones than ligaments, leading to avulsion fractures rather than ligament sprains
10
Q
Risk factors for strains and sprains
A
- Poor ergonomics
- Deconditioned or unstretched muscles
- Body habitus
- Environment
- Specific activities
- Fatigue
- Increased age with reduced physical activity
- Overuse
- Previous injury
11
Q
History in strains and sprains
A
- Popping, snapping, or tearing sensation at time of event
- Followed by pain, swelling, stiffness
- Difficulty bearing weight/reduced ability to use the extremity involved
- Bruising and discoloration may appear within 24-48 hours
12
Q
Physical exam findings for both strains and sprains
A
- Asymmetric swelling
- Tenderness
- Ecchymosis
13
Q
Physical exam findings for muscle strain
A
- Visible and/or palpable defect may be seen/felt
- Pain with active and passive flexion of the muscle
- Loss of active muscle contraction to move joint –> complete rupture of the muscle
14
Q
Physical exam findings with ligament sprain
A
- Pain with active and passive ROM
- Joint instability/laxity
- More common for higher grade (III) sprains
- Special tests may be beneficial to determine specific ligament
15
Q
What is a grade 1 muscle strain?
A
Tear of a few muscle fibers (<10%); fascia intact
16
Q
What is a grade 2 muscle strain?
A
- Tear of moderate amount of muscle fibers (10-50%), fascia intact
17
Q
What is a grade 3 muscle strain?
A
- Tear of most or all fibers (50-100%), fascia intact
18
Q
What is a grade 4 muscle strain?
A
Tear of all muscle fibers (100%), fascia disrupted
19
Q
What is a grade 1 ligament sprain?
A
Mild; a tear of only a few fibers of the ligament; no joint instability
20
Q
What is a grade 2 ligament sprain?
A
Moderate; partial tear of the ligament; some laxity with stress maneuvers
21
Q
What is a grade 3 ligament sprain?
A
- Severe; complete tear of the ligament
- Joint laxity with stress maneuvers
22
Q
Diagnosis of strains and sprains
A
- Most often clinical, labs and imaging not necessary
- X-ray utilized if high concern for fracture
- MRI to confirm or grade strains/sprains
23
Q
Indications for X-ray in suspected strain/sprain
A
- Positive Ottawa Ankle Rules
- Worsening pain/swelling with appropriate management
- Persistent pain/swelling after 7-10 days of appropriate management
24
Q
Ottawa ankle rules
A
Ankle Sprains:
* Pain at medial malleolus or along distal 6 cm of the posterior/medial tibia
* Pain at the lateral malleolus or along the distal 6 cm of the posterior fibula
* Inability to bear weight immediately and for four consecutive steps in the emergency department
Foot sprains:
* Pain in the midfoot and at the base of the fifth metatarsal
* Pain in the midfoot and at the navicular bone
* Inability to bear weight immediately and for four consecutive steps in the emergency department
25
Indications for MRI for strains and sprains
* Suspected rupture or severe sprain
* Surgical intervention is likely
26
Healing process of strains and sprains
* Phase 1: hemostasis
* Phase 2: inflammatory phase
* Phase 3: proliferative phase
* Phase 4: maturation phase
27
Pathophysiology of phase 1 of strains and sprains
* Hemostasis
* Platelets aggregate and release cytokines, chemokines, and hormones
* Vasoconstriction occurs to limit bleeding into affected area causing temporary skin blanching
* Clot formation occurs
28
Pathophysiology of phase 2 of strains/sprains
* Onset 0-72 hours post injury
* Inflammatory/Destruction phase
* Results from tearing of the myofibers, ligament fibers, and microvasculature
* 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 and increase in the concentration of local inflammatory mediators
29
Pathophysiology of phase 3 of strains and sprains?
* 72 hrs - 3 weeks
* Proliferative/reparative/fibroblastic phase
* Granulation tissue formed
* Collagen deposition occurs
* Neovascularization at the injury, supporting tissue healing
* Inflammatory mediators are reduced
30
Pathophysiology of phase 4 of strains and sprains
* 3 wks - 2 yrs
* Maturation/remodeling phase
* Collagen and myofibers increase in number, strength, and organization
31
Management of hemostasis/inflammatory phase (day 0-3)
* Protection/compression of the injured area and rest
* Control pain and swelling ICE
32
Management of reparative phase (day 3-week 3)
* Continued protection with pain and swelling control
* Full AROM
* Progressive muscular strength, endurance, and power
33
Management of maturation phase of strains and sprains (wk 3- 2 years)
* Maintenance of ROM and flexibility
* Increased muscular strength, endurance and power
* Increased speed and agility
34
What is indicated in inflammatory phase of healing
PRICE
* Protection: padding, slings, braces, ACE wraps, air splint
* Rest: no additional force should be applied; avoid weight bearing
* Ice: ASAP to reduce pain and swelling through vasoconstriction for 15-20 minutes every 2-3 hours for the first 48 hours
* Compression: compression bandages (ACE) to limit swelling
* Elevation: ideally above the heart
* Heat should be avoided during this phase
35
Contraindications to ice in the inflammatory phase
* Raynaud's
* PVD
* Impaired sensation
* Cold allergy/hypersensitivity
* Severe cold induced urticaria
36
Treatment of complete tear of muscle, tendon, or ligament
* Surgical repair
* Refer if joint instability, failure of conservative therapy, neurovascular compromise
37
What can be used for pain management in strains/sprains?
* NSAIDs first line
* Opioids may be needed based on severity of pain/injury
38
What should be done following PRICE?
* Weight-bearing
* ROM exercise
* Strength training
* Start low and go slow
* Consider referral to physical therapy
39
What is overuse syndrome
Umbrella term encompassing diagnosis that results from overuse of a musculoskeletal component
40
MOA of 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
41
Who more likely gets overuse syndrome
* Very common with athletes
* Sport may lead to your diagnosis
42
Extrinsic factors causing overuse syndrome?
* Repetitive mechanical load
* Increased duration, frequency, intensity, technique errors
* Equipment problems: poor footwear, racquet size, running surface
43
What anatomic factors can cause overuse syndrome?
* Malalignment
* Inflexibility
* Muscle weakness
* Muscle imbalance
* Decreased vascularity
44
Age-related factors causing overuse syndrome
* Tendon degeneration
* Decreased healing response
* Increased tendon stiffness
45
Systemic factors causing overuse syndrome
* Inflammatory disorders
* Quinolone-induced tendinopathy
46
Presentation of overuse syndrome
* Pain
* Muscle fatigue
* Numbness
* Swelling
* Symptoms tend to develop and slowly progress over time
* Pain may be localized to the tendinous insertion and exacerbated by muscle stretch or contraction
47
Work up of overuse syndrome
* Thorough and complete H&P considering aggravating/alleviating factors, repetitive activities, work environments
* PE: muscle testing, ROM, and special testing if indicated
* Radiograph: calcification or spur formation of tendon at insertion site
* Bone scans and MRIs: stress fractures, osseous pathology
* NCS/EMGs: if neurologic s/s
48
Management of overuse syndrome
* Most are mild and will resolve spontaneously
* Avoidance of the activity that led to syndrome
* Patient education
* Pain management --> ice/heat, NSAIDs, corticosteroid injections
* PT: home exercise programs
* OT: workplace modifications
* Referral to ortho if conservative tx fails
49
What is the periosteum
* Thick outer layer
* Contains vessels, nerve endings and cells that repair fractures
50
What is the endosteum
* Inner lining of the marrow cavity
51
What is the epiphysis?
* Contains epiphyseal plate (growth plate/physis)
* Very vascular and prone to infection and fractures
* Present on child at end of growth plate and not on adult
52
What is metaphysis
* Spongy, cancellous bone
* Most susceptible to compression fractures
53
What is diaphysis
* Thick cortical bone
* Provides most of the structural support of the long b one
54
What is a fracture
Disruption in the continuity or structural integrity of a bone
55
MOA of fractures
* Stress applied to the bone greater than the bone's intrinsic strength
* Can also occur pathologically
* All bones can fracture but extremities at highest risk
56
History in fractures
* Often hx of trauma
* Pain worsened by movement
* Localized tenderness
* +/- deformity
* +/- numbness/tingling
57
Physical exam in fractures
* Always inspect bones/joint above and below injury
Inspection
* Edema, ecchymosis
* Deformity
* Skin integrity
Palpation
* Tenderness, crepitus
* Evaluate joint stability
* Assess NV status
58
Imaging for fractures
* First line: radiograph
* CT or MRI --> indicated if diagnosis needs confirmed or to further define a complex fracture prior to surgical repair
59
Components of describing a fracture
* Open vs closed
* Location
* Orientation/direction: communuted vs segmented, compression vs impaction
* Displacement: degree of angulation and direction
60
Gustilo and Anderson classification grade I
* Low energy injury with an open wound <1 cm in legnth and no evidence of contamination
61
Gustilo and Anderson classification grade II
* Moderate injury with comminution of the fracture and a 1- to 10 cm wound with some contamination
62
Gustilo and Anderson classification grade IIIA
High-energy fracture apttern with a wound >10 cm and gross contamination
63
Gustilo and Anderson classification grade IIIB
High energy fracture with a >10 cm contaminated wound with exposed bone
63
Grade IIIC gustilo and anderson classification
Similar to grade IIIB with vascular involvement
64
Fracture location description
* Diaphysis/shaft: location on bone shaft
* Distal or proximal metaphysis (end of adult bone or neck of child)
* Epiphysis/growth plate
* Anatomical name of the bone
65
Transverse fracture
Fracture perpendicular to the shaft of the bone
66
Oblique fracture
Angulated fracture line
67
Spiral fracture
Multiplanar and complex fracture line
68
Comminuted fracture
Fracture in which there are more than two fracture fragments
69
Segmental comminuted fracture
Type of comminuted fracture in which there are 2 fracture lines isolating a segment of bone
70
Avulsed fracture
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
71
Compression fracture
Common with osteoporosis type of impaction that occurs in the vertebrae
72
Intra-articular fracture
Crosses the articular cartilage and enters the joint
73
Non-displaced
Fragments are in anatomic alignment
74
Displaced
Fracture is no longer in anatomic alignment
75
How is severity of displaced fracture annotated?
in mm or % with regard to the direction the distal fragment is offset in relation to the proximal fragment
76
Angulated fracture displacement
* Bone fragments are misaligned
* Described as the degree and direction of deviation of the distal fragment
* Could be medial, ventral, lateral, dorsal
77
Bayoneted fracture displacement
Distal fragment longitudinally overlaps the proximal fragment
78
Distracted fracture displacement
Distal fragment is separated from the proximal fragment by a gap described by mm/cm
79
Rotational deformity displacement
* Degree the distal fragment is twisted on axis of normal bone
* Usually detected by physical exam
80
Make sure to look at the practice displacement questions to ensure you understand!
Okay fine!
81
What is a torus (buckle) fracture?
* Incomplete fracture along distal metaphysis where bone is most spongy
* MC in distal radius
* May be very subtle --> important to look at multiple views on x-ray
* Common in pediatrics
82
What is a greenstick fracture?
* Common in pediatrics
* Fracture that doesn't extend through the entire periosteum
* Occurs in pediatric population due to soft bone
* Fracture on the tension side and buckle on the other side of the shaft of a long bone
83
Salter-Harris classification
* Used to describe fractures involving growth plate
84
When does growth plate closure usually occur?
* Depends on specific bone and age of patient
* Females average 12-14
* Males 14-16
85
86
87
88
Go back and look over Salter Harris classification!
Got it!
88
What can assist in detecting fractures in skeletally immature children?
Comparison of unaffected side
## Footnote
lack of ossification of epiphyses in young children can make fracture identification difficult
88
Salter harris classification mneumonic
* S: slipped (type I) - some people say straight across, through growth plate
* A: above (type II), does not affect joint, through growth plate and metaphysis
* L: lower (type III), affects the joint, through growth plate and epiphysis
* TE: through everything (type IV), through all three elements
* R: rammed (type V), crush injury of growth plate
89
What are the 3 phases of fracture healing?
* Stage 1: Inflammatory phase
* Stage 2: reparative phase
* Stage 3: remodeling phase
90
What are characteristics of the inflammatory phase of fracture healing?
* Immediately bleeding from the fracture site and surrounding tissue occurs
* Peaks after several days, bioactive cells migrate to fracture site hematoma leading to formation of granulation tissue
91
What are characteristics of reparative phase of fracture healing?
* Neovascularization promotes the healing process
* Necrotic debris is removed by phagocytes and fibroblasts begin to produce collagen
* Soft callus produced first
* Then mineralization begins to slowly convert woven/immature bone
92
What are characteristics of the remodeling phase of fracture healing?
* Overlaps with repair phase and can continue for several months
* Woven (immature) bone is replaced with more mature lamellar bone
* Typically around 6-10 weeks
93
Indications for immediate orthopedic consultation with fracture?
* Open fracture
* Displaced fracture
* Unstable fracture
* Irreducible fracture
* Fractures complicated by compartment syndrome
* Nerve or vascular injury in fracture
94
What guides closed fracture management?
* Bone involved
* Type of fracture
* Degree of displacement
* Open vs. Closed
95
What is management of axial fracture?
Bed rest and non-weight bearing
## Footnote
Hip, pelvis, spine
96
Management of closed extremity fracture
* Reduction if displaced or angulated
* Moderate-severe displacement/angulation requires surgical intervention with ORIF (open reduction and internal fixation with plates, screws, pins or intramedullar devices)
* Immobilization: splints, casting, slings
* Bed rest
* Elevation
* Avoidance of weight bearing
* Further evaluation by a specialist
97
Open fracture management
* Orthopedic emergency!! High risk of osteomyelitis, compartment syndrome, and neurovascular injury
* Require irrigation/debridement followed by sterile dressing
* NPO
* Pain medication
* Broad spectrum IV antibiotics
* Update Td if applicable
98
Type I and II open fracture IV antibiotics
* 1st generation cephalosporin: cefazolin
* If at risk for anaerobic infection, add metronidazole
99
Type III open fracture IV antibiotics
* 1st generation cephalosporin (cefazolin)
* +aminoglycoside (gentamicin)
* If at risk for anaerobic infection (ie farm injury or necrosis) add metronidazole
100
Factors that worsen prognosis of fractures
* Skeletal maturity
* Fractures of multiple bones in the extremity
* Intra-articular fractures
* Marked displacement of fractures
* Unstable vertebral factures
* Comminuted, oblique, and segmental fractures
101
Adverse outcomes from fractures
* Malunion
* Nonunion
* Stiffness, muscle atrophy: early PT can prevent
* Arthritis: associated with intra-articular fx
* Vascular or nerve injury
* Compartment syndrome
* Osteonecrosis
102
Malunion
* Inadequate alignment of fracture
* Results from inappropriate reduction, immobilization, or surgical error in alignment
103
Treatment of malunion
Osteotomy or bone cuts to restore anatomical alignment
104
Nonunion diagnostic criteria
* Lack of healing within 6 months of a injury
* No healing progress in 3 consecutive months
105
Factors that affects nonunion healing
* Smoking
* Indolent infection
* Inadequate immobilization
* Malnutrition
* NSAID use significant
* Soft tissue injury
106
Treatment options for nonunion fractures
* Surgical fixation
* Bone graft
* Electrical/US stimulation
107
What is a stress fracture?
Fracture in normal bone that has been subjected to repeated or continuous loads that in and of themselves are not sufficient to cause a fracture
108
Causes of stress fracture
* Small number of repetitions with a relatively large load
* Large number of repetitions with a usual load
* Common in athletes, especially runners
109
Risk factors for stress fracture
* Prior stress fracture
* Low level of fitness
* Increasing volume and intensity of physical activity
* Female gender, especially when combined with menstrual irregularity (+eating disorder = triad)
* Eating disorders (female athlete triad)
* Diets poor in calcium and vitamin D
* Poor bone health
* Poor biomechanics
110
History with stress fracture
* Gradual onset, localized pain
* Worse with significant activity initially
* Less activity can produce pain as fracture progresses
* Look at risk factors
111
Physical exam with stress fracture
Localized tenderness over injury site
112
Imaging in stress fracture
* If doubting diagnosis
* Plain radiographs should be obtained initially due to high specificity, may not appear on radiographs for weeks
* If suspicion high and diagnosis needs confirmed, MRI, CT, or bone scan
113
Management of stress fracture
* Based on fracture site
* Conservative management for low-risk fractures
* Surgery for high-risk fractures
114
What locations are considered low-risk fractures?
* Fx of 2nd-4th metatarsal shafts
* Posteromedial tibial shaft
* Fibula
* Proximal humerus or humeral shaft
* Ribs, sacrum, and pubic rami
115
Conservative therapy for stress fracture
* Acute pain control
* Reduced weight bearing or splinting
* Reduction or modification of activities
* Rehabilitative exercise to promote optimal biomechanics
* Reduce risk factors
116
High-risk stress fracture locations
* Pars interarticularis of lumbar spine
* Femoral head and neck
* Patella
* Anterior cortex of tibia
* Medial malleolus
* Talus, tarsal navicular
* Proximal 5th metatarsal shaft, great toes sesamoids, base of second metatarsal bone
117
When should referral to orthopedist for stress fracture be done immediately?
* High risk fractures
* Lengthy rehab program inappropriate
* Conservative treatment fails
118
Goals of splinting
* Reduce pain, bleeding, and swelling of injury site and surrounding areas
* Immobilize the injury
* Prevent further damage of the muscles, nerves and blood supply
* Prevent further laceration of the skin and contamination of an open wound
118
Indications for splinting
* Fractures
* Dislocations
* Severe sprains
119
Splinting instructions
* Remove clothing to fully inspect area
* Check NV status distal to injury before and after splint
* Clean all wounds and cover with dry, sterile dressing
* Immobilize above and below fracture bone
* Intra-articular fx immobilize above and below joint fracture
* Pad all rigid splints to prevent local injury
* While applying splint, minimize movement of the limb and support injury site until splint has set
* Attempt to reduce any severely deformed limb with constant gentle traction
* If resistance is encountered, splint in position of deformity
120
Splinting types
* Prefabricated plastic splints
* Air splints
* Fabric splints
* Metal splints
* Plaster and fiberglass splints
121
What is splint of choice when expected to remain in place for more than a few hours?
Plaster and fiberglass splints
122
Splinting materials
* Cast padding and stockinette
* Prefabricated plaster or fiberglass splints
* Rolls of plaster or fiberglass splinting material
* Elastic bandage
* Water
* Non-sterile gloves
123
Optimal timing for cast placement
* After swelling has resolved, 5-7 days after unless fracture is unstable
* Splints useful in meantime
124
Standard for closed, nondisplaced/reduced fractures
Casting
125
Materials needed for casting
* Stockinette
* Cast padding
* Fiberglass or plaster casting "tape"
126
Casting PEARLS
* Application similar to splinting
* Always note neurovascular status
* Follow up x-rays help document continued bone healing and union
* Important to tell patients to keep both splints and casts dry
* Patient's must return to have cast removed
