103 Musculoskeletal Traumas

8/9/2019 103 Musculoskeletal Traumas

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MUSCULOSKELETALMUSCULOSKELETAL

TRAUMASTRAUMAS

SPRAIN, STRAIN, FRACTURE,SPRAIN, STRAIN, FRACTURE,

DISLOCATIONDISLOCATION



SPRAIN VS. STRAINSPRAIN VS. STRAIN A A sprainsprain isis aa stretchingstretching or or tearingtearing of of ligamentsligaments,, thethe tough,tough,

fibrousfibrous bandsbands of of tissuetissue thatthat connectconnect bonesbones toto oneone another another atat aa joint joint..

A A strainstrain isis aa stretchingstretching or or tearingtearing of of tendontendon or or musclemuscletissue,tissue, commonlycommonly calledcalled aa pulledpulled musclemuscle..

EtiologyEtiology

Anything Anything thatthat placesplaces suddensudden or or unaccustomedunaccustomed stressstress onon ----or or chronicchronic overuseoveruse of of ---- joints joints or or musclesmuscles maymay causecause aasprainsprain or or strainstrain..

Falls,Falls, liftinglifting heavyheavy objects,objects, exertionexertion of of anan unfamiliar unfamiliar sportsport

BeingBeing overweight,overweight, inactive,inactive, or or inin poor poor physicalphysical conditionconditionboostsboosts thethe likelihoodlikelihood of of injuryinjury..

ImproperlyImproperly warmingwarming upup andand notnot stretchingstretching musclesmuscles beforebeforeintenseintense physicalphysical activityactivity



Ankle SprainAnkle Sprain

*May be due*May be due

to suddento sudden

twisting/ankletwisting/ankleinversioninversion

*Most*Most

common:common:

Talofibular Talofibular ligamentligament





What are the signs of a sprain?What are the signs of a sprain?

While the intensity varies,While the intensity varies, pain, bruising, swelling,pain, bruising, swelling,andand inflammationinflammation are common to all threeare common to all threecategories of sprains: mild, moderate, severe.categories of sprains: mild, moderate, severe.

The individual will usually feelThe individual will usually feel a tear or pop in thea tear or pop in the joint. joint.

A severe sprain produces excruciating pain at the A severe sprain produces excruciating pain at themoment of injury, as ligaments tear completely, or moment of injury, as ligaments tear completely, or separate from the bone.separate from the bone.

This loosening makes the joint nonfunctional.This loosening makes the joint nonfunctional.

A moderate sprain partially tears the ligament, A moderate sprain partially tears the ligament,producingproducing joint instability joint instability, and some swelling., and some swelling.

A ligament is stretched in a mild sprain, but there A ligament is stretched in a mild sprain, but thereis no joint loosening.is no joint loosening.



STRAINSTRAIN*Tendinitis/ elbow*Tendinitis/ elbowstrainstrain*Hamstring & Achilles*Hamstring & Achillestendon straintendon strain



What are the signs of a strain?What are the signs of a strain?

Typical indications includeTypical indications include pain, musclepain, musclespasm, muscle weakness, swelling,spasm, muscle weakness, swelling,inflammation, and crampinginflammation, and cramping..

In severe strains, the muscle and/or tendonIn severe strains, the muscle and/or tendonis partially or completely ruptured, oftenis partially or completely ruptured, oftenincapacitating the individual.incapacitating the individual.

Some muscle function will be lostSome muscle function will be lost with awith a

moderate strain, where the muscle/tendon ismoderate strain, where the muscle/tendon isoverstretched and slightly torn.overstretched and slightly torn.

With a mild strain, the muscle/tendon isWith a mild strain, the muscle/tendon isstretched or pulled, slightly.stretched or pulled, slightly.



Severity

Physical

Examination

Findings Impairment Pathophysiology Typical Treatment

Grade 1 Minimal

tenderness and

swelling

Minimal Microscopic

tearing of

collagen fibers

Weight bearing as tolerated

No splinting/casting

Isometric exercises

Full range-of-motion and

stretching/ strengthening

exercises as tolerated

Grade 2 Moderate

tenderness andswelling

Decreased

range of

motion

Possibleinstability

Moderate Complete tears

of some butnot all collagen

fibers in the

ligament

Immobilization with air

splintPhysical therapy with range-

of-motion and stretching/

strengthening exercises

Grade 3 Significant

swelling and

tenderness

Instability

Severe Complete tear/

rupture of

ligament

Immobilization

Physical therapy similar to that

for grade 2 sprains but over a

longer period

Possible surgical reconstruction



Sprain and StrainSprain and Strain

Grade 1Grade 1 : stretching injury: stretching injury

Grade 2Grade 2 : partial tearing: partial tearing Grade 3Grade 3 : complete tearing/torn: complete tearing/torn

Acute Management includes PRICESM Acute Management includes PRICESM

ProtectionProtection

RRestest

IIce packce pack CCompressionompression

EElevationlevation

SupportSupport

MedicationMedication

After 48 hours: After 48 hours:

Progressive ROM exercisesProgressive ROM exercises

PassivePassive Active assistive Active assistive Active Active

ResistiveResistive

Hot / Warm compressHot / Warm compress



Imaging TestsImaging Tests

XX--raysrays

Magnetic Resonance Imaging (MRI)Magnetic Resonance Imaging (MRI)

Surgical options include:Surgical options include:

ArthroscopyArthroscopy

A surgeon looks inside the joint to see if there A surgeon looks inside the joint to see if thereare any loose fragments of bone or cartilage, or are any loose fragments of bone or cartilage, or

part of the ligament caught in the joint.part of the ligament caught in the joint.

ReconstructionReconstruction

A surgeon repairs the torn ligament with A surgeon repairs the torn ligament withstitches or suture, or uses other ligamentsstitches or suture, or uses other ligaments

and/or tendons found in the foot and aroundand/or tendons found in the foot and around

the ankle to repair the damaged ligaments.the ankle to repair the damaged ligaments.



PreventionPrevention

The best way to prevent ankle sprains is to maintainThe best way to prevent ankle sprains is to maintaingood strength, muscle balance and flexibility.good strength, muscle balance and flexibility.

Participate in a conditioning program to build muscleParticipate in a conditioning program to build musclestrengthstrength

Do stretching exercises dailyDo stretching exercises daily

Always wear properly fitting shoes Always wear properly fitting shoes

Nourish your muscles by eating a wellNourish your muscles by eating a well--balanced dietbalanced diet

Warm up before any sports activity, including practiceWarm up before any sports activity, including practice

Use or wear protective equipment appropriate for thatUse or wear protective equipment appropriate for that

sportsport Pay attention to your body's warning signs to slowPay attention to your body's warning signs to slow

down when you feel pain or fatiguedown when you feel pain or fatigue

Pay attention to walking, running or working surfacesPay attention to walking, running or working surfaces



FRACTUREFRACTURE

Any break in the continuity of bone; broken Any break in the continuity of bone; broken

bonebone

May be traumatic or pathologicMay be traumatic or pathologic Direct blowDirect blow

Sudden twistingSudden twisting

Severe muscle contractionSevere muscle contraction

SportsSports--related injuryrelated injury

Secondary to disease that has weakened the bonesSecondary to disease that has weakened the bones





ClassificationClassification

According to communication to the According to communication to theenvironmentenvironment

Closed/ Simple fxClosed/ Simple fx

Open/ Compound fxOpen/ Compound fx

CompletenessCompleteness Complete fxComplete fx

Incomplete fxIncomplete fx

Anatomical position Anatomical position Proximal 1/3Proximal 1/3

Middle 1/3Middle 1/3

Distal 1/3Distal 1/3



According to According to line of breakageline of breakage//

displacementdisplacement

Transverse fxTransverse fx Longitudinal fxLongitudinal fx

Oblique fxOblique fx

Spiral fxSpiral fx

Other classificationOther classification

Comminuted fxComminuted fx

Greenstick fxGreenstick fx

Impacted fxImpacted fx

Distraction fxDistraction fx

Compression fxCompression fx





Garden¶s classification of femoral FxGarden¶s classification of femoral Fx Type I : incomplete femoral neck fx;Type I : incomplete femoral neck fx;

intertrochanteric crest fxintertrochanteric crest fx

Type II : complete femoral neck fx;Type II : complete femoral neck fx;

intertrochanteric + lesser trochanter fxintertrochanteric + lesser trochanter fx

Type III : complete femoral neck fx + <50% displacement;Type III : complete femoral neck fx + <50% displacement;intertrochanteric + greater trochanter fxintertrochanteric + greater trochanter fx

Type IV : complete femoral neck fx + > 50% displacement;Type IV : complete femoral neck fx + > 50% displacement;intertrochanteric + lesser + greater trochanter fxintertrochanteric + lesser + greater trochanter fx

Salter Salter--Harris classificationHarris classification Type I : growth plateType I : growth plate

Type II : metaphysis and growth plateType II : metaphysis and growth plate

Type III : epiphysis and growth plateType III : epiphysis and growth plate

Type IV : metaphysis and epiphysisType IV : metaphysis and epiphysis

Type V : crushing injuryType V : crushing injury







Signs and SymptomsSigns and Symptoms

Usually, you will know immediately if you haveUsually, you will know immediately if you havebroken a bone«broken a bone«

may hear may hear a snap or cracking sounda snap or cracking sound

The area around the fracture will be tender andThe area around the fracture will be tender and

swollenswollen

A limb A limb may be deformedmay be deformed, or a part of the bone, or a part of the bone

may puncture through the skin.may puncture through the skin.

Stress fractures are more difficult to diagnose,Stress fractures are more difficult to diagnose,because they may not immediately appear on anbecause they may not immediately appear on an

XX--ray; however, there may beray; however, there may be pain, tendernesspain, tenderness

and mild swelling.and mild swelling.



Document neurovascular examination (and addressDocument neurovascular examination (and addressdeficits immediately)deficits immediately)

Perform on initial exam and repeat before andPerform on initial exam and repeat before andafter any interventionafter any intervention

Keep high index of suspicion for CompartmentKeep high index of suspicion for CompartmentSyndromeSyndrome

Check capillary refill and distal pulsesCheck capillary refill and distal pulses

Check motor and Sensory ExaminationCheck motor and Sensory Examination Evaluate skin over fracture siteEvaluate skin over fracture site

Signs of open fractureSigns of open fracture

Signs of displaced fracture (skin tenting)Signs of displaced fracture (skin tenting)

Clues suggesting fracture (swelling, Ecchymosis,Clues suggesting fracture (swelling, Ecchymosis,and point tenderness over fracture site)and point tenderness over fracture site)

Devitalized skin at risk of necrosisDevitalized skin at risk of necrosis

Evaluate joints, muscles, ligaments, and tendonsEvaluate joints, muscles, ligaments, and tendonsabove and below the fractureabove and below the fracture



Indications: Referral to OrthopedicsIndications: Referral to Orthopedics

Emergent referral indicationsEmergent referral indications

Fracture with neurologic deficitFracture with neurologic deficit

Fracture with vascular deficitFracture with vascular deficit

Fracture with secondary Compartment SyndromeFracture with secondary Compartment Syndrome

Open fractureOpen fracture

Severe crush or shearing injury resulting in skinSevere crush or shearing injury resulting in skin

devitalizationdevitalization



Principles in FracturePrinciples in Fracture

ManagementManagement Reduction/ Bone setting/ RealignmentReduction/ Bone setting/ Realignment

Open reductionOpen reduction (e.g. ORIF),(e.g. ORIF), Closed ReductionClosed Reduction //

Careful manipulation,Careful manipulation, TractionTraction Immobilization/Maintenance of reductionImmobilization/Maintenance of reduction

Internal fixationInternal fixation (metal pins, rods, nails, screws,(metal pins, rods, nails, screws,

plates),plates), External fixationExternal fixation (casts, molds, braces),(casts, molds, braces),

TractionTraction Rehabilitation/ Restoration of functionRehabilitation/ Restoration of function

Progressive exercisesProgressive exercises



DISLOCATIONDISLOCATION

Displacement of bones from its articulatingDisplacement of bones from its articulatingsurfacessurfaces



DislocationDislocation

May be congenital, traumatic andMay be congenital, traumatic andpathologicpathologic

CompleteComplete : bones are displaced and not: bones are displaced and notin contact to the articulating surfacein contact to the articulating surface

IncompleteIncomplete : partial/subluxation; bones: partial/subluxation; bonesare displaced but still in contact to itsare displaced but still in contact to itsarticulating surfacearticulating surface

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103 Musculoskeletal Traumas