Soft Tissue Injury Flashcards Preview

Skin MS: Week 6 > Soft Tissue Injury > Flashcards

Flashcards in Soft Tissue Injury Deck (68):
1

What is soft tissue?

Articular cartilagen, tendon, ligament, fibrocartilage (i.e. meniscus, labrum), muscle

2

What can happed to articular cartilage?

Osteochondral defect, chondromalacia

3

What can happen to tendons?

Tenosynovitis, tendinopathy, tendon strain, tendon rupture

4

What can happen to ligament?

Sprain, tear

5

What can happen to Fibrocartilage? 

Tear

6

What can happen to muscle?

Strain, cramping, contusion, myositis ossificans, compartment syndrome

7

Mechanisms of ligamentous injury

Repetitive stress (overuse), acute high-force injury 

8

Ligament injury exam

Swelling, joint deformity, pain w/ palpation, ROM limited by pain (guarding), joint instability w/ stress

9

Joint instability tests (ACL, UCL, ATFL)

Lachman, Pivot Shift (ACL)

Milk jug sign (UCL in thumb)

Ankle Anterior Drawer (ATFL)

10

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.

11

Ottawa Ankle Rules 

1. Patient has pain in the malleolar zone (or under achilles)

2. 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

12

Lateral condyle of tibia avulsion fracture on xray --> 

ACL tear

13

Ligament Injury Tx

•Relative rest

•Immobilization (Brace, Splint, Cast)

•Rehab of surrounding structures/PT

•Surgical repair/reconstruction

14

Does torn ligament need surgery?

It depends! (Benefit vs risk)

15

Consequences of deficient ligament?

Early arthritis, secondary soft tissue injury, joint instability/disabilitiy

16

Surgical ligaments

–UCL thumb

–Scapholunate Ligament

–UCL elbow

–Glenohumeral*

–Coraco-clavicular

–ACL

–Tib-Fib/Syndesmosis

–ATFL

–Deltoid

–Lisfranc

17

Injury to tendon can involve 

tendon, paratenon (more fibrous coating), tendon sheath (synovial membrane)

(or combination)

18

De Quervain's Tenosynovitis

Tendon sheath swollen and inflammed as runs under extensor retinaculum (EPB and APL)

19

Most tendon issues are not _____ but are ______

inflammatory

Usually degenerative

20

Tendinopathy

Primarily degenerative (not inflammatory) - microtears 

Activity-related pain (more repetitive us)

Focal tendon tenderness

 

 

21

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)

22

_______ strengthening most effective for tendinopathy

eccentric most effective 

23

Tendon tearing predisposed by 

Degenerative changes (age, maybe asymptomatic), malalignment, muscle imbalance, weakness, instabilty, inflexibility, glucocorticoids, fluorinated quinolones, inadequate blood supply 

24

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

25

Special tendon injury tests

Empty Can – Supraspinatus

Thompson’s Test – Achilles (squeeze calf --> plantarflex)

Hook Test – Distal Biceps (hook the tendon w/ finger)

26

Biceps supinate/pronate

supinate 

*There are other flexors, but the supination will be why they need surgery 

27

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 

28

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

29

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

30

3 (important) types fibrocartilage 

Glenoid labrum

Acetabular labrum

Meniscus

31

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

32

Fibrocartilage injury

Tramautic tears - young/active, sudden change in direction

Degenerative - aging, no specific injury, associated w/ age-related tissue changes (i.e. OA)

33

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)

34

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

35

Imaging for fibrocartilage exam

Imaging important, US does not work (too far into joint)

MRI (meniscus)

MRI-arthrogram (glenoid and acetabular labrum) - contrast dye

36

2 important Glenoid labral tear

SLAP (superior labral): 2-10, biceps origin, athletes

Bankart (anterior inferior dislocation): 3-6

37

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

38

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

39

Big concern w/ skeletal muscle and injury

Generate heat --> hyperthermia 

40

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

41

Muscle strain prevention 

•Flexibility

•Warm-up - Temperature, Extensibility

•Conditioning - Avoids fatigue

•Strength  - Able to absorb more energy

42

Muscle Strain Tx

•Rest

•Ice

•Compression

•Elevation

•NSAIDS

•Mobilization

•Rehabilitation

43

Muscle cramping = cause

uncertain

dehydration

electrolyte disturbances (salty sweaters, Na, Ca, Mg)

Muscle fatigue

44

Most common muscle to cramp

Gastrocnemius

45

Medications associated given for muscle cramping

quinine sulfate (tonic water), chloroquine sulfate 

46

Muscle contusions

•Direct trauma causing damage and partial disruption of muscle fibers

•Intramuscular hematoma frequently results

47

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)

48

Muscle contusions characterized by 

•Characterized by tenderness, swelling or palpable hematoma, limits in strength/motion

49

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

50

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

51

Acute compartment syndrome

•Assoc with direct trauma to bone or soft tissue

•Elevated compartmental pressure compromises tissue perfusion

Surgical emergency - fasciotomy 

52

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 

53

Chronic Compartment Syndrome

•Treatment

–Relative rest, cross-training, activity modification

–Physical therapy, biomechanical correction

–Fasciotomy

54

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

55

Articular Cartilage Injury

Acute - tear, osteochondral defect

Repetitive excessive loading - chondromalacia

56

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

57

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

58

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

59

Chondromalacia tx

–Ice, relative rest, acetaminophen, NSAIDS, steroid injections

–Physical Therapy – muscle balance and joint stability

60

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)

61

Causes of bursitis

•Etiology

–Direct trauma

–Prolonged pressure

–Overuse

–Crystaline Arthropathy

–Inflammatory arthritis

–Infection (septic bursitis)

62

Common bursitis locations

•Common Locations

–Subacromial space

–Greater Trochanter

–Olecranon

–Prepatellar/infrapatellar

–Iliopsoas

63

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

64

Bursitis tx

•Protection

•Ice

•NSAIDs

•Steroid injection

–Concern for introduction of infection with needle

•Bursectomy

65

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 

66

FDP Rupture (Jersy Finger)

Flexor Digitorum Profundus - treat early to regain function in finger 

67

Unhappy triad

Valgus stress - 

ACL, MCL, medial meniscus 

68