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PBL Week 11 > Soft tissue injuries profoma > Flashcards

Soft tissue injuries profoma Flashcards

1
Q

Management for soft tissue injuries

A
  • Analgesia e.g. NSAIDs or steroids
  • RICE
  • Immobilisation - e.g. splint, sling, brace
  • Physiotherapy
  • Surgical repair e.g. meniscal resection
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2
Q

Where can soft tissue injuries occur?

A
  • skin
  • meniscal injury
  • blood vessels
  • tendons
  • ligaments
  • pain caused by lymph
  • bursa- bursitis
  • nerve pain
  • fascia
  • fat
  • joint capsule
  • muscle
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3
Q

What are the types of skin injury?

A
  • 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
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4
Q

What is cellulitis?

A
  • Bacterial soft tissue infection - most commonly staph. aureus.
  • Needs antibiotics & monitoring.
  • Differential for Gout & Necrotising faciitis
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5
Q

What are Baker’s cyst?

A
  • 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
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6
Q

Meniscal injuries: what are the menisci?

A
  • 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

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7
Q

Aetiology of meniscal injury

A
  • 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

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8
Q

Presentation of meniscal injuries

A
  • 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.
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9
Q

Investigations for meniscal injuries

A
  • X-ray - exclude fracture and OA
  • MRI - confirms prescence of torn menisci
  • Arthroscopy of knee
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10
Q

Leg pain caused by blood vessels

A

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.

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11
Q

Blood vessels: deep vein thrombosis- what is it? presentation, treatment, investigations, risk factors?

A

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

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12
Q

Tendons- tendinopathy: what is it, clinical presentations, investigations & management

A

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

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13
Q

Tendinopathy: examples of conditions?

A
  1. Rotator Cuff
    - Beneath the acromion is the subacromial space.
    - If space becomes narrowed, irritation of supraspinatus can occur giving rise to tendinopathy.
  2. 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

  1. 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

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14
Q

Tendons- tenosynovitis: what is it? Clinical features? Management?

A

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

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15
Q

Tenosynovitis: examples of conditions?

A
  1. 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

  1. 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.
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16
Q

Tendons-rupture: what is it, presentation, investigation, management?

A

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.

17
Q

Tendon rupture: examples of conditions?

A
  1. 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

  1. 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

  1. Mallet finger
    - Extensor tendon rupture of distal phalanx
    - Results in Flexion of DIP joint
    - Inability to extend DIP joint
  2. Patellar tendon
18
Q

Tendons: what is enthesitis?

A

inflammation of the
entheses, the sites
where tendons or
ligaments insert into
the bone.

19
Q

Ligaments- ACL tear: presentation, clinical examination, investigation, management

A

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

20
Q

Ligaments: PCL- aetiology, presentation, Examination, investigation and management?

A

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.

21
Q

Ligaments- Collateral cruciate ligaments: aetiology, presentation, examination & management

A

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.

22
Q

Ligaments- ankle strain: aetiology, presentation, investigation & management

A

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

23
Q

Pain caused by lymph?

A

Drains fluid from tissues

Surgery e.g. breast cancer can distrupt the normal flow of lymph = develop swelling (lymphodema)

24
Q

What is a bursa?

A

Lined w/ epithelium

produces synovial fluid- small sacs of synovial fluid

Point where muscles & tendons slide across bone

reduces friction & trauma

25
Q

What are common locations for bursitis?

A

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

26
Q

What are some causes of muscle pain?

A
  • 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
27
Q

What are causes of nerve pain?

A

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

28
Q

What are causes of fascia pain?

A
  1. 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
  2. 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.
  3. Compartment syndrome
29
Q

What are causes of joint capsule pain?

A
  • Synovitis
  • Frozen shoulder (adhesive capsulitis) - inflammation of the joint capsule causing it to tighten = restriction of movement. Diabetes is a risk factor for this.
30
Q

What is lymphodema? Causes? Symptoms? Treatment?

A

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

PBL Week 11 (12 decks)

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