Soft Tissue MSK Injuries, Chris Parfitt MD FRCS

1. Soft Tissue MSK InjuriesSoft Tissue MSK Injuries
Chris Parfitt MD FRCS©Chris Parfitt MD FRCS©

2. Rural OrthopedicsRural Orthopedics
• Salmon arm
• Revelstoke
• Nakusp
• Clearwater
• Valemont
• Mcbride

3. When the X-ray is negativeWhen the X-ray is negative

4. The Sprain Brain DrainThe Sprain Brain Drain
• The diagnosis of
sprain generally
means we don’t know
exactly what is injured
BUT:
• We assume…
• The condition will get
better with or without
ancillary therapies
• And the condition
does not need any
further thought from
us

5. Injured limbInjured limb
• HISTORY
• OBSERVATION
• XRAY
• COMPLETE PHYSICAL EXAM (this is
what is forgotten)

6. PrinciplesPrinciples
• Let me know if
this principle is
not apparent

7. Prize QuestionsPrize Questions
• Students and
residents get first
chance
• Then open to the floor

8. PRETESTPRETEST
• The worse you do on
the pretest, the better
for the teacher

9. An acute Boutonniere deformityAn acute Boutonniere deformity
1. Results from a tear of conjoint tendon
2. Always requires surgery
3. Can be managed with a paper clip splint
4. Results from avulsion of the central slip
5. Can be managed by a rural family doctor

10. Jersey FingerJersey Finger
1. Is a common sprain that occurs milking
Jersey cows
2. Cannot be diagnosed clinically
3. Characterized by loss of fds funtion
4. Can be managed by the rural family
doctor
5. Always requires referral to a plastic
surgeon

11. A Stener lesionA Stener lesion
• Is caused by being shot by a Sten gun
• Is characterized by loss of flexion of the
pip joint
• Can only be diagnosed at time of surgery
• Mention of this lesion can get a surgeon to
see the patient

12. Distal Biceps AvulsionDistal Biceps Avulsion
1. Cannot be diagnosed clinically
2. Can be treated non surgically
3. Can occur with minimal injury
4. Can be treated successfully by the rural
family doctor

13. The Hook signThe Hook sign
• 1. is found in compartment syndrome
• 2. is performed in pronation and flexion
• 3. is not very sensitive or reliable
• 4. can be used for clinical diagnosis of
distal biceps tear
• 5. none of the above

14. Acute Compartment SyndromeAcute Compartment Syndrome
1. Can be successfully managed by waiting
until the 5 “P”’s are noted
2. Occurs only after fractures and burns
3. Must be diagnosed by measurement of
compartment pressures
4. Can be managed by the rural family
physician

15. What is true about TAL tearsWhat is true about TAL tears
1. Surgery is always required
2. No treatment gives equal results to
surgical care
3. Physiotherapists often make the
diagnosis
4. Can be treated successfully by the rural
family doctor with surgical skills

16. DisclosureDisclosure
Do I have any conflict of interest or bias
regarding equipment supply companies,
Well…yes!

17. DisclosuresDisclosures
• ACME Co
manufacturing
company
• I have always been
on the side of the
coyote and ACME Co

18. Upper LimbUpper Limb
• Mallet finger

19. Mallet FingerMallet Finger
• Either a tendinous
injury
• More common

20. Mallet FingerMallet Finger
• Or a bone injury
• Less common

21. Mallet Finger RXMallet Finger RX
• Stack splint
6 weeks full time
4 weeks part time
Delayed treatment OK

22. Boney MalletBoney Mallet
• If more than 40% of
joint involved refer
• Otherwise treat in
stack splint for 4 to 5
weeks
• Heals quicker!

23. Acute Boutonniere deformityAcute Boutonniere deformity
Normal structure of the
central slip and the
lateral bands

24. Acute Boutonniere injuryAcute Boutonniere injury
• Avulsion of the
central slip of the
extensor tendon at
the base of the
middle phalanx

25. Acute Boutonniere injuryAcute Boutonniere injury
• PIP falls into flexion
• Lateral bands sublux
volarly and
hyperextend the DIP
joint

26. Acute boutonniere deformityAcute boutonniere deformity
• Starts as a sprained
finger
• Evolves into pip
flexion and dip
extension

27. Boutonniere injury TreatmentBoutonniere injury Treatment
• Safety pin splint
• Refer to Physio or OT
• 6 to 8weeks
treatment

28. Jersey FingerJersey Finger
• Also called football
finger
• Inability to flex the dip

29. Jersey FingerJersey Finger
• Avulsion of the FDP
from the distal
phalanx with or
without a fragment of
bone
• Types 1 to 4

30. Jersey Finger diagnosisJersey Finger diagnosis
• X-ray may show bone
fragment
• Diagnosis is clinical
by testing flexor
digitorum profundus

31. Jersey Finger RXJersey Finger RX
• Referral to plastics

32. Skier’s thumbSkier’s thumb
• Acute rupture of ulnar
collateral ligament of
thumb

33. Skier’s thumb dxSkier’s thumb dx
• History of injury to
thumb
• Tenderness over the
ulnar collateral
ligament

34. Skier’s thumb dxSkier’s thumb dx
• X-rays are usually
negative
• Can be positive
showing some bone
avulsion

35. Skier’s Thumb DxSkier’s Thumb Dx
• Stress test
• Local anaesthetic
• Full extension

36. Skier’s Thumb AssessmentSkier’s Thumb Assessment
• Stress test
• In flexion as well

37. Skier’s Thumb AssessmentSkier’s Thumb Assessment
• >30 degrees relative
instability is
diagnostic of
complete ulnar
collateral ligament
tear

38. Skier’s Thumb Stener LesionSkier’s Thumb Stener Lesion
• With full tear of the
ulnar collateral
ligament the proximal
ligament retracts and
lays on top of the
adductor aponeurosis

39. Skier’s thumb RXSkier’s thumb RX
• Less than 30 degrees
instability
• less than one 2 inch
roll of fibreglass
• 5 to 6 weeks

40. Skier’s Thumb TreatmentSkier’s Thumb Treatment
• >30 degrees
instability
• surgery

41. DISTAL BICEPS AVULSIONDISTAL BICEPS AVULSION
• Elbow sprain
• Occurs when patient
is flexing
• Counterforce (puck)
extends
• May be POPping
sound

42. Biceps avulsion: DiagnosisBiceps avulsion: Diagnosis
• Reverse POPEYE
muscle
• Not always this clear,
but nice when present

43. Biceps avulsion: Hook testBiceps avulsion: Hook test
• Patient supinates arm
at 90 degrees flexion
• Your index finger tries
to hook the tendon
from the lateral side
• Highly sensitive and
specific

44. Biceps AvulsionBiceps Avulsion
• TAX
• (take an X-ray)

45. Distal Biceps Avulsion MRIDistal Biceps Avulsion MRI
• Clinical diagnosis
very good
• Let the surgeon
decide on need for
MRI
• Partial tears need
MRI for assessment

46. Distal Biceps Tears RXDistal Biceps Tears RX
• Always surgical ?
• Bury the tendon into
its original footprint of
the radial tuberosity

47. Proximal rupture BicepsProximal rupture Biceps
• Rupture of long head
• Very common
• Usually older age
group
• Rupture of short head
rare (never seen it)

48. Rupture Long Head BicepsRupture Long Head Biceps
• Patient usually feels a
pop

49. Rupture Long head bicepsRupture Long head biceps
POPEYE muscle
What?
Medical myths?

50. Real Picture Rupture ProximalReal Picture Rupture Proximal
BicepsBiceps
• Biceps bunched up
distally a bit
• Held by short head

51. In all fairness to PopeyeIn all fairness to Popeye
• The biceps do
sometimes appear

52. Proximal rupture biceps RXProximal rupture biceps RX
• Most proximal
ruptures are
associated with
tendon degeneration
and rotator cuff
pathology
• These (mostly in older
less active patients
can be treated
conservatively

53. Rupture long head biceps RXRupture long head biceps RX
• Non operative
treatment usually
results in loss of 20 %
supination strength
• Surgical indications
for younger
individuals who need
full supination
strength

54. Take home MessageTake home Message
• Middle age and older
patients with non
labour occupations
• Younger patients with
higher energy injury
and need for full
strength (minority of
cases)
• Sling, pain control,
physiotherapy
• Refer for surgical
treatment

55. Tendo Achilles tearsTendo Achilles tears
• Occurs in sports or
activities like pushing
cars in the snow
• Patient reports being
kicked in the heel
• Often a pop heard
• Male 6 :1

56. Tendo Achilles DXTendo Achilles DX
• Up to 20 % of TAL
tears are not clinically
clear
• Swelling or partial
tear

57. • History
• Physical
examination
DiagnosisDiagnosis

58. Achilles tendon tearAchilles tendon tear
• Thompson test

59. Tendo Achilles tears DXTendo Achilles tears DX
• Ultrasound or MRI
can be used if clinical
exam is not
convincing
• U/S 100% sensitive
and 94% accurate

60. Tendo Achilles Tears RXTendo Achilles Tears RX
• CAST IN EQUINUS • SURGERY AND
CAST IN EQUINUS

61. Medical Evidence HierarchyMedical Evidence Hierarchy
• Level one studies
• 2
• 3
• 4
• 5 expert opinion
• Best
• worst

62. Tendo Achilles RXTendo Achilles RX
• Level one studies
support cast regimen
treatment
• No surgical
complications

63. Tendo Achilles tearsTendo Achilles tears
• controversies • Increased re-rupture
tear with non
operative treatment
• tendon heals
elongated with
conserative treatment

64. Tendo Achilles tears: compromiseTendo Achilles tears: compromise
• 1. Call orthopod and
pass responsibility
• 2. Agree with
surgeon to treat
conservatively or
send for surgery

65. Tendo Achilles Cast RXTendo Achilles Cast RX
• Regimen
• Cast in equinus
• In cast for 6 or more
weeks
• Neutral position at 4
weeks
• Non weight bearing
• Heel lift for 4 weeks
• Physiotherapy

66. Tendo Achilles RXTendo Achilles RX
• Newer studies suggest that use of
functional brace and
• Functional rehab (early ROM and weight
bearing) may be acceptable
• KEEP TUNED IN

67. Tendo achilles tearsTendo achilles tears
• Take home message
• Share responsibility
with ortho
• Especially for more
active individuals
• Use cast with
acceptable protocol
for progressive ROM
and weight bearing

68. Tendo Achilles tears RXTendo Achilles tears RX
• Surgery still an
option for patients
with high activity

69. Knee extensor injuriesKnee extensor injuries
• Can be tear of the
quadriceps tendon, or
the patellar tendon
• Presents as a
SPRAINED KNEE

70. Knee extensor injuries DXKnee extensor injuries DX
• Clinical Exam may
show a soft tissue
dibit

71. Extensor injuriesExtensor injuries
• Examination shows a
lack of active
extension
• Best tested on
crutches at partial
gravity

72. Knee Extensor Tears XRAYKnee Extensor Tears XRAY
• Valuable
• May see elevated patella
• May see fragments of bone above patella

73. Knee extensor injuries DXKnee extensor injuries DX
• Ultrasound is
sensitive

74. Knee Extensor tears DXKnee Extensor tears DX
• MRI

75. Knee extensor tearsKnee extensor tears
• Take Home
• Diagnose clinically
• Confirm with U/S
• Refer for surgery

76. Ankle sprainsAnkle sprains
• Occurs with inversion
injury (most
common)
• Grade 1
• Rx with semi rigid
brace helpful

77. Ankle SprainsAnkle Sprains
• Grade 2
• Rx with semi rigid
brace and physio
helpful

78. Ankle SprainsAnkle Sprains
• Grade 3
• Treat with cast for 10
days
• Then semi rigid brace
• Physio helpful

79. Ankle sprain SurgeryAnkle sprain Surgery
• No robust evidence to
suggest surgery over
conservative care for
3rd
degree tears
(Cochrane 2007)

80. Ankle ligament TearsAnkle ligament Tears
• Take home message
• Treat all with brace,
or cast and physio
and followup
• Call surgeon for high
level patients with
marked instability

81. COMPARTMENTCOMPARTMENT
SYNDROMESYNDROME
THE BIG ONE! Don’t let it getTHE BIG ONE! Don’t let it get
awayaway

82. Compartment syndromeCompartment syndrome
• Situation where you
have to think fast and
take the right action
• Otherwise the
outcome is bad

83. Compartment Syndrome PrognosisCompartment Syndrome Prognosis
• Treatment in < 6
hours gives good
result
• Treatment in 6 to 12
hours gives 68%
normal function
Treatment in > 12 hours
only 8 % normal
function

84. Compartment syndromeCompartment syndrome
• One of biggest
causes of lost
medicolegal cases

85. Compartment syndrome: causesCompartment syndrome: causes
• Most common cause
is forearm and tibial
fractures
– BUT

86. Compartment syndrome: causesCompartment syndrome: causes
• Burns
• Envenomation
• Decreased osmolality
(nephrotic syndrome)
• Hemorrhage
• DVT
• Ruptured bakers cyst
• Hemophilia
• Influenza myositis
• Androgen abuse
• Rhabdomyolysis

87. Compartment syndrome: causesCompartment syndrome: causes
• Any condition that
alters consciousness
• Patient lays on the
part for a prolonged
time
• Arm under body
causes pressure of
150 mm hg

88. Compartment syndrome: causesCompartment syndrome: causes
Iatrogenic causes
Should we include
Oxycontin
prescription?
• Any injection or
vascular cannulation
particularly in
anticoagulated patient
• Tight cast
• Intraosseous infusion
• ETC

89. Compartment syndrome: causesCompartment syndrome: causes
• The bottom line
• Can present in numerous clinical
situations
• BE CAREFUL OUT THERE

90. PATHYSIOPHYSIOLOGYPATHYSIOPHYSIOLOGY
• Fascial compartments
all over the limbs,
most clearly in
forearm and lower leg

91. PATHOPHYSIOLOGYPATHOPHYSIOLOGY
• Final common
pathway
• Pressure increase
prevents venous
outflow (low pressure)
• Arterial pressure
(high) keeps pouring
in

92. PATHOPHYSIOLOGYPATHOPHYSIOLOGY
• VICIOUS CIRCLE
• Ischemia
• Skeletal muscle
reacts to ischemia by
releasing histamines
that increase vascular
permeability

93. Compartment Syndrome DXCompartment Syndrome DX
• 5 P’s
• Pain
• Paresthesia
• pallor
• Pulseless
• Poikilothermia
• FORGET THE LAST
3
• Call your lawyer

94. Compartment syndrome: DXCompartment syndrome: DX
PAIN
out of proportion to the
clinical picture
Acronym POP

95. Compartment syndrome DXCompartment syndrome DX
• Pain with passive
motion of joint distal
to compartment
• Also active range

96. Compartment syndrome DXCompartment syndrome DX
• Paresthesias
• Occurs later, usually
prior to irreversible
changes

97. Compartment syndrome: DXCompartment syndrome: DX
• Interesting fact
• 50 % patients with
compartment > 30
had 2 point
discrimination > 1 cm
in median nerve
distribution

98. Compartment syndrome DXCompartment syndrome DX
• Compartment may
feel tense
• Like wood

99. Compartment syndrome: TestsCompartment syndrome: Tests
• Compartment
pressure testing
• Useful but not iron
clad
• UNAVAILABLE to you

100. Compartment syndrome:TestsCompartment syndrome:Tests
• Order CPK, urine,
myoglobulin studies
and renal function
tests
• CPK > 1000 units
suggestive of
compartment
syndrome

101. Compartment Syndrome RXCompartment Syndrome RX
• If patient has swollen
and painful part, but
no clear signs of
compartment
syndrome, then
• REEXAMINE with any
clinical change for the
worse

102. Compartment Syndrome RXCompartment Syndrome RX
1. Swollen limb
2. Pain out of
proportion
3. Tense compartment
4. Pain with passive
motion
5. Paresthesia
6. ACT

103. What the non-surgeon can doWhat the non-surgeon can do
• DIAGNOSIS
• AWARENESS OF
DIAGNOSIS

104. What the non-surgeon can doWhat the non-surgeon can do
• Place limb at level of
heart (not higher)
• BIVALVE all casts,
splints and split
padding

105. What the non-surgeon can doWhat the non-surgeon can do
• Split cast
• Bivalve cast
• Take off cast
• Split padding
• 30 % reduction
pressure
• Further 35%
reduction pressure
• Further 15%
reduction
• 10 to 15 % reduction
pressure

106. URGENT SURGERYURGENT SURGERY
• RECOGNIZE TIME
CONSTRAINTS
• If you are a GP
surgeon or have a
general surgeon
available, this may be
the only time to save
the limb

107. SIMILAR TO C SECTIONSIMILAR TO C SECTION
• IT IS BETTER TO DO THE C SECTION
UNNECESSARILY THAN NOT TO DO
ONE THAT IS NEEDED
• IT IS BETTER TO DO A FASCIOTOMY
UNNECESSARILY THAN NOT TO DO
ONE THAT IS NEEDED

108. REVENGE ON CITY SURGEONSREVENGE ON CITY SURGEONS
• Keep the surgical
techniques book
available
• Telephone
consultation with
orthopedic surgeon
• Cut and send

109. Compartment Syndrome RXCompartment Syndrome RX
Fasciotomy
Easy surgery, wonderful
benefit
EASY SURGERY!

110. Post testPost test
• You have to ace this to make the teacher
look good

111. What is true about TAL tearWhat is true about TAL tear
• 1. Surgery is always indicated
• 2. No treatment gives equal results to
surgical care
• 3. Studies comparing surgical to non
surgical care are not well done
• 4. Physiotherapists often make the DX
• 5. Can be treated by rural family docs

112. Acute Boutonniere injuryAcute Boutonniere injury
• 1. Results from a tear of the conjoint
tendon
• 2. Always requires surgery
• 3. Can be managed with a paper clip
splint
• 4. Results from the avulsion of the central
slip
• 5. Can be managed by the rural family doc

113. Distal Biceps AvulsionDistal Biceps Avulsion
• 1. Cannot be diagnosed clinically
• 2. Can be treated non surgically
• 3. Can occur with minimal injury
• 4. Can be treated by rural family doc

114. Acute compartment syndromeAcute compartment syndrome
• 1. Can be successfully managed by
waiting until the 5 ‘P’s are noted
• 2. Occurs only after fracture and burns
• 3. Must be diagnosed by measurement of
compartment pressures
• 4. Can be managed by the GP surgeon

115. Jersey FingerJersey Finger
• 1. A common sprain that occurs milking
Jersey cows
• 2. Cannot be diagnosed clinically
• 3. Characterized by loss of FDS function
• 4. Can be managed by the rural family
doc
• 5. Always requires referral to a hand
surgeon

116. A Stener lesionA Stener lesion
• 1. Caused by being shot by a sten gun
• 2. Characterized by loss of flexion of the
PIP joint
• 3. Can only be diagnosed at time of
surgery
• 4. Mention of this lesion can get a
surgeon’s attention and expedite the
referral

117. Prize QuestionPrize Question
• What is the diagnosis
in this patient with a
sprained knee

118. Soft Tissue MSK injuriesSoft Tissue MSK injuries
• QUESTON PERIOD