Soft tissue injuries profoma Flashcards
(30 cards)
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
