Adult Medical-Surgical Adult Medical-Surgical NursingNursing

Musculo-skeletal Module: Musculo-skeletal Module: Sports/ Soft Tissue InjuriesSports/ Soft Tissue Injuries

Musculo-skeletal Trauma/Musculo-skeletal Trauma/Common Sports InjuriesCommon Sports Injuries

Contusion: soft tissue bruisingContusion: soft tissue bruising Strain: pulled muscleStrain: pulled muscle Sprain: damaged joint ligaments Sprain: damaged joint ligaments Dislocation: joint out of positionDislocation: joint out of position Subluxation: partial dislocationSubluxation: partial dislocation Tendonitis: inflammation of tendonsTendonitis: inflammation of tendons Ruptured tendonRuptured tendon Torn meniscusTorn meniscus Fracture (see lecture) Fracture (see lecture)

Soft Tissue Injuries: Soft Tissue Injuries: PathophysiologyPathophysiology

Sudden strain, twisting, tearing or Sudden strain, twisting, tearing or dislocation (trauma) leads to: dislocation (trauma) leads to:

Inflammatory responseInflammatory response to neutralise, to neutralise, control and wall-off the injured area control and wall-off the injured area and prepare for repair and prepare for repair

Soft Tissue Injuries: Soft Tissue Injuries: Inflammatory ResponseInflammatory Response

MediatedMediated by chemicals, histamine, by chemicals, histamine, kinins (bradykinin), prostaglandin from kinins (bradykinin), prostaglandin from injured tissue. Leads to:injured tissue. Leads to:

VasodilationVasodilation/ increased blood supply / increased blood supply Increased Increased vascular permeabilityvascular permeability and and

infiltration of leucocytes for infiltration of leucocytes for phagocytosisphagocytosis of debris/ pathogens of debris/ pathogens

Fibrinogen to fibrin for clotting (to Fibrinogen to fibrin for clotting (to wall-off/ prevent systemic infection) wall-off/ prevent systemic infection)

Inflammatory Response: Inflammatory Response: Clinical EffectsClinical Effects

The clinical effects of the increased The clinical effects of the increased blood flow and vascular permeability blood flow and vascular permeability are:are:

Pain (congestion of the area/ kinins)Pain (congestion of the area/ kinins) HeatHeat SwellingSwelling RednessRedness Loss of function Loss of function

Soft Tissue Injury/ SprainSoft Tissue Injury/ Sprain

Sprain: DescriptionSprain: Description

Damage to the ligaments of a joint Damage to the ligaments of a joint as a result of sudden abnormal or as a result of sudden abnormal or amplified, extended movementamplified, extended movement

Soft Tissue Injury/ Sprain: Soft Tissue Injury/ Sprain: Clinical ManifestationsClinical Manifestations

Pain on movementPain on movement Pain at restPain at rest SwellingSwelling BruisingBruising Restricted range of movement from Restricted range of movement from

pain and oedemapain and oedema General symptoms: nausea, General symptoms: nausea,

faintness at time of injury faintness at time of injury

Soft Tissue Injury/ Sprain: Soft Tissue Injury/ Sprain: DiagnosisDiagnosis

Usually diagnosed by patient history Usually diagnosed by patient history and clinical pictureand clinical picture

Soft Tissue Injury/ Sprain: Soft Tissue Injury/ Sprain: ManagementManagement

Rest Rest Ice Ice Compression Compression ElevationElevation Analgesia and anti-inflammatory Analgesia and anti-inflammatory

drugsdrugs Gradual exercise with rehabilitationGradual exercise with rehabilitation

Joint Dislocation/ SubluxationJoint Dislocation/ Subluxation

Joint Dislocation: DescriptionJoint Dislocation: Description

Damage with Damage with displacementdisplacement of a joint of a joint as a result of sudden abnormal or as a result of sudden abnormal or amplified, extended movementamplified, extended movement

Involves muscles, ligaments, tendonsInvolves muscles, ligaments, tendons

Joint Dislocation: Joint Dislocation: Clinical ManifestationsClinical Manifestations

Severe acute pain on slightest Severe acute pain on slightest movement with faintness, nauseamovement with faintness, nausea

Dull ache or pain at restDull ache or pain at rest Deformity of jointDeformity of joint Possible swelling or bruising Possible swelling or bruising Reduced range of movementReduced range of movement Possible numbness, tingling, Possible numbness, tingling,

coolness, discoloration of affected coolness, discoloration of affected limb (neurovascular involvement)limb (neurovascular involvement)

Joint Dislocation: DiagnosisJoint Dislocation: Diagnosis

Patient historyPatient history

Clinical pictureClinical picture

XrayXray

MRI for soft tissue injuryMRI for soft tissue injury

Joint Dislocation: ManagementJoint Dislocation: Management

ImmobilisationImmobilisation Reduction under anaesthesia Reduction under anaesthesia

(displaced parts into position)(displaced parts into position) Support in correct position Support in correct position

(bandages, slings, splints)(bandages, slings, splints) Analgesia, anti-inflammatory drugs, Analgesia, anti-inflammatory drugs,

muscle relaxantsmuscle relaxants Observe neurovascular statusObserve neurovascular status Gradual rehabilitation exercisesGradual rehabilitation exercises

Injury to TendonsInjury to Tendons

Common Injury to Tendons: Common Injury to Tendons: ClassificationClassification

Ruptured Achilles tendon (calf)Ruptured Achilles tendon (calf)

Rotator Cuff tears (acromioclavicular Rotator Cuff tears (acromioclavicular joint/ shoulder): acute injury or joint/ shoulder): acute injury or chronic joint stresschronic joint stress

Tendonitis: “Tennis Elbow” (affects Tendonitis: “Tennis Elbow” (affects wrist grasp also)wrist grasp also)

Ruptured Achilles TendonRuptured Achilles Tendon

Ruptured Achilles Tendon:Ruptured Achilles Tendon:DescriptionDescription

A sudden acute tear of the Achilles A sudden acute tear of the Achilles tendon usually in a sports activitytendon usually in a sports activity

Ruptured Achilles Tendon: Ruptured Achilles Tendon: Clinical ManifestationsClinical Manifestations

Sudden acute, extreme pain in calf Sudden acute, extreme pain in calf areaarea

Inability to plantar flexInability to plantar flex

Shock, nausea, faintnessShock, nausea, faintness

Ruptured Achilles Tendon: Ruptured Achilles Tendon: DiagnosisDiagnosis

Patient historyPatient history

Clinical PictureClinical Picture

Xray: exclude bony injuryXray: exclude bony injury

Ruptured Achilles Tendon: Ruptured Achilles Tendon: ManagementManagement

Immediate analgesiaImmediate analgesia Prompt repair under anaesthesiaPrompt repair under anaesthesia Immobilise with plaster castImmobilise with plaster cast Elevate and restElevate and rest Observe circulation to toesObserve circulation to toes Static quads exercises: improve Static quads exercises: improve

circulation/ muscle tonecirculation/ muscle tone Progressive physio: promotes ankle Progressive physio: promotes ankle

strength/ movement until full weight-strength/ movement until full weight-bearing bearing

Rotator Cuff Tears:Rotator Cuff Tears:

Rotator Cuff Tears: DescriptionRotator Cuff Tears: Description

Acute or chronic shoulder tendon Acute or chronic shoulder tendon injuryinjury

Rotator Cuff Tears: Rotator Cuff Tears: Clinical ManifestationsClinical Manifestations

Painful shoulder jointPainful shoulder joint Limited range of movementLimited range of movement Some joint dysfunction/ muscle Some joint dysfunction/ muscle

weaknessweakness Unable to perform over the head Unable to perform over the head

activitiesactivities Night pain: unable to sleep on Night pain: unable to sleep on

affected sideaffected side Acromioclavicular joint is tenderAcromioclavicular joint is tender

Rotator Cuff Tears: Rotator Cuff Tears: DiagnosisDiagnosis

Patient historyPatient history Clinical pictureClinical picture Xray (joint structure) Xray (joint structure) Arthrography Arthrography MRI (soft tissue/ extent of rotator cuff MRI (soft tissue/ extent of rotator cuff

tear)tear)

Rotator Cuff Tears: Rotator Cuff Tears: ManagementManagement

Anti-inflammatory drugsAnti-inflammatory drugs Rest and modify activityRest and modify activity Local corticosteroid injection (joint)Local corticosteroid injection (joint) Progressive strengthening exercisesProgressive strengthening exercises SurgerySurgery if unresolved: arthroscopic if unresolved: arthroscopic

debridement or tendon repairdebridement or tendon repair Immobilisation of shoulder up to 4 Immobilisation of shoulder up to 4

weeks then physio weeks then physio

““Tennis Elbow”: TendonitisTennis Elbow”: Tendonitis

““Tennis Elbow”/ Tendonitis: Tennis Elbow”/ Tendonitis: DescriptionDescription

Excessive repetitive activities of the Excessive repetitive activities of the forearm causing inflammation and forearm causing inflammation and minor tears of the tendons (affecting minor tears of the tendons (affecting elbow and wrist grasp)elbow and wrist grasp)

A chronic painful conditionA chronic painful condition

““Tennis Elbow”/ Tendonitis:Tennis Elbow”/ Tendonitis:Clinical ManifestationsClinical Manifestations

Pain which characteristically radiates Pain which characteristically radiates down the dorsal surface of the down the dorsal surface of the forearmforearm

Weakened graspWeakened grasp

Diagnosis from history and clinical Diagnosis from history and clinical picturepicture

““Tennis Elbow”/ Tendonitis: Tennis Elbow”/ Tendonitis: ManagementManagement

Rest and avoid aggravating activityRest and avoid aggravating activity Anti-inflammatory drugsAnti-inflammatory drugs Immobilisation in splint may be Immobilisation in splint may be

helpfulhelpful Corticosteroid injection locally if Corticosteroid injection locally if

other measures not effectiveother measures not effective Rehabilitation exercises to gradually Rehabilitation exercises to gradually

stretch the tendons stretch the tendons Support strap to prevent recurrence Support strap to prevent recurrence

Meniscal InjuryMeniscal Injury

Meniscal Injury (Torn Meniscus): Meniscal Injury (Torn Meniscus): DescriptionDescription

The menisci are the 2 semi-lunar The menisci are the 2 semi-lunar cartilages of the knee joint attached cartilages of the knee joint attached to the head of tibia allowing to the head of tibia allowing articulation with the femur articulation with the femur

Meniscal Injury: Meniscal Injury: Aetiology Aetiology

Injury and tearing away from the Injury and tearing away from the tibia occurs with:tibia occurs with:

Excessive twisting of the knee Excessive twisting of the knee

Repetitive squatting and impactRepetitive squatting and impact

Mostly sports injuryMostly sports injury

Meniscal Injury:Meniscal Injury:PathophysiologyPathophysiology

Loose cartilage in knee joint slips Loose cartilage in knee joint slips between tibia and femur interfering between tibia and femur interfering with movementwith movement

Inflammatory process set up in Inflammatory process set up in responseresponse

Meniscal Injury (Knee Joint):Meniscal Injury (Knee Joint):Clinical ManifestationsClinical Manifestations

Inability to fully extend the legInability to fully extend the leg If happens during walking/ running: If happens during walking/ running:

leg “gives way”. It is painful and leg “gives way”. It is painful and unexpectedunexpected

Clicking of the knee on extension/ Clicking of the knee on extension/ weight-bearingweight-bearing

Locking of the kneeLocking of the knee Inflammation and swelling/ effusion Inflammation and swelling/ effusion

of knee joint (torn cartilage)of knee joint (torn cartilage)

Meniscal Injury (Knee Joint):Meniscal Injury (Knee Joint):DiagnosisDiagnosis

Patient history and clinical picturePatient history and clinical picture

Meniscal Injury (Knee Joint):Meniscal Injury (Knee Joint):ManagementManagement

Conservative management:Conservative management: Immobilisation of the kneeImmobilisation of the knee Crutches and modification of Crutches and modification of

activitiesactivities Anti-inflammatory medicationsAnti-inflammatory medications If symptoms persist:If symptoms persist: Arthroscopy to determine damage Arthroscopy to determine damage

and surgery: Meniscectomy (removal and surgery: Meniscectomy (removal of torn cartilage)of torn cartilage)

Meniscectomy: Meniscectomy: Post-operative CarePost-operative Care

Pressure dressing applied to knee to Pressure dressing applied to knee to prevent effusionprevent effusion

Immobilisation with splintImmobilisation with splint Rest with leg elevatedRest with leg elevated Static quads/straight-leg-raising Static quads/straight-leg-raising

exercisesexercises If effusion occurs (painful): If effusion occurs (painful): Aspirated to relieve pressureAspirated to relieve pressure Usually able to resume normal activities Usually able to resume normal activities

in daysin days

Sports/ Soft Tissue Injuries: Sports/ Soft Tissue Injuries: Nursing ConsiderationsNursing Considerations

Emotional/ psychological support Emotional/ psychological support throughout carethroughout care

Stay with patient at time of injuryStay with patient at time of injury Ensure prompt analgesia/ comfortEnsure prompt analgesia/ comfort Observe vital signs/ neurovascular Observe vital signs/ neurovascular

function of affected limbfunction of affected limb Hand-washing and aseptic techniqueHand-washing and aseptic technique Encourage appropriate exercises Encourage appropriate exercises