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Soft tissue msk injuries
- 1. Soft Tissue MSKInjuriesSoft 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-rayis negativeWhen the X-ray is negative
- 4. The Sprain BrainDrainThe 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 meknow if this principle is not apparent
- 7. Prize QuestionsPrize Questions •Students and residents get first chance • Then open to the floor
- 8. PRETESTPRETEST • The worseyou do on the pretest, the better for the teacher
- 9. An acute BoutonnieredeformityAn 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 lesionAStener 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 AvulsionDistalBiceps 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 signTheHook 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 SyndromeAcuteCompartment 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 trueabout 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 haveany 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 RXMalletFinger 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 deformityAcuteBoutonniere deformity Normal structure of the central slip and the lateral bands
- 24. Acute Boutonniere injuryAcuteBoutonniere injury • Avulsion of the central slip of the extensor tendon at the base of the middle phalanx
- 25. Acute Boutonniere injuryAcuteBoutonniere injury • PIP falls into flexion • Lateral bands sublux volarly and hyperextend the DIP joint
- 26. Acute boutonniere deformityAcuteboutonniere deformity • Starts as a sprained finger • Evolves into pip flexion and dip extension
- 27. Boutonniere injury TreatmentBoutonniereinjury 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 diagnosisJerseyFinger diagnosis • X-ray may show bone fragment • Diagnosis is clinical by testing flexor digitorum profundus
- 31. Jersey Finger RXJerseyFinger RX • Referral to plastics
- 32. Skier’s thumbSkier’s thumb •Acute rupture of ulnar collateral ligament of thumb
- 33. Skier’s thumb dxSkier’sthumb dx • History of injury to thumb • Tenderness over the ulnar collateral ligament
- 34. Skier’s thumb dxSkier’sthumb dx • X-rays are usually negative • Can be positive showing some bone avulsion
- 35. Skier’s Thumb DxSkier’sThumb Dx • Stress test • Local anaesthetic • Full extension
- 36. Skier’s Thumb AssessmentSkier’sThumb Assessment • Stress test • In flexion as well
- 37. Skier’s Thumb AssessmentSkier’sThumb Assessment • >30 degrees relative instability is diagnostic of complete ulnar collateral ligament tear
- 38. Skier’s Thumb StenerLesionSkier’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’sthumb RX • Less than 30 degrees instability • less than one 2 inch roll of fibreglass • 5 to 6 weeks
- 40. Skier’s Thumb TreatmentSkier’sThumb Treatment • >30 degrees instability • surgery
- 41. DISTAL BICEPS AVULSIONDISTALBICEPS AVULSION • Elbow sprain • Occurs when patient is flexing • Counterforce (puck) extends • May be POPping sound
- 42. Biceps avulsion: DiagnosisBicepsavulsion: Diagnosis • Reverse POPEYE muscle • Not always this clear, but nice when present
- 43. Biceps avulsion: HooktestBiceps 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 AvulsionMRIDistal Biceps Avulsion MRI • Clinical diagnosis very good • Let the surgeon decide on need for MRI • Partial tears need MRI for assessment
- 46. Distal Biceps TearsRXDistal Biceps Tears RX • Always surgical ? • Bury the tendon into its original footprint of the radial tuberosity
- 47. Proximal rupture BicepsProximalrupture Biceps • Rupture of long head • Very common • Usually older age group • Rupture of short head rare (never seen it)
- 48. Rupture Long HeadBicepsRupture Long Head Biceps • Patient usually feels a pop
- 49. Rupture Long headbicepsRupture Long head biceps POPEYE muscle What? Medical myths?
- 50. Real Picture RuptureProximalReal Picture Rupture Proximal BicepsBiceps • Biceps bunched up distally a bit • Held by short head
- 51. In all fairnessto PopeyeIn all fairness to Popeye • The biceps do sometimes appear
- 52. Proximal rupture bicepsRXProximal 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 headbiceps 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 MessageTakehome 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 tearsTendoAchilles 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 DXTendoAchilles DX • Up to 20 % of TAL tears are not clinically clear • Swelling or partial tear
- 57.
- 58. Achilles tendon tearAchillestendon tear • Thompson test
- 59. Tendo Achilles tearsDXTendo 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 TearsRXTendo Achilles Tears RX • CAST IN EQUINUS • SURGERY AND CAST IN EQUINUS
- 61. Medical Evidence HierarchyMedicalEvidence Hierarchy • Level one studies • 2 • 3 • 4 • 5 expert opinion • Best • worst
- 62. Tendo Achilles RXTendoAchilles RX • Level one studies support cast regimen treatment • No surgical complications
- 63. Tendo Achilles tearsTendoAchilles 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 CastRXTendo 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 RXTendoAchilles 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 tearsTendoachilles 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 tearsRXTendo Achilles tears RX • Surgery still an option for patients with high activity
- 69. Knee extensor injuriesKneeextensor injuries • Can be tear of the quadriceps tendon, or the patellar tendon • Presents as a SPRAINED KNEE
- 70. Knee extensor injuriesDXKnee 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 TearsXRAYKnee Extensor Tears XRAY • Valuable • May see elevated patella • May see fragments of bone above patella
- 73. Knee extensor injuriesDXKnee extensor injuries DX • Ultrasound is sensitive
- 74. Knee Extensor tearsDXKnee Extensor tears DX • MRI
- 75. Knee extensor tearsKneeextensor 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 SurgeryAnklesprain Surgery • No robust evidence to suggest surgery over conservative care for 3rd degree tears (Cochrane 2007)
- 80. Ankle ligament TearsAnkleligament 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 PrognosisCompartmentSyndrome 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: causesCompartmentsyndrome: causes • Most common cause is forearm and tibial fractures – BUT
- 86. Compartment syndrome: causesCompartmentsyndrome: causes • Burns • Envenomation • Decreased osmolality (nephrotic syndrome) • Hemorrhage • DVT • Ruptured bakers cyst • Hemophilia • Influenza myositis • Androgen abuse • Rhabdomyolysis
- 87. Compartment syndrome: causesCompartmentsyndrome: 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: causesCompartmentsyndrome: 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: causesCompartmentsyndrome: causes • The bottom line • Can present in numerous clinical situations • BE CAREFUL OUT THERE
- 90. PATHYSIOPHYSIOLOGYPATHYSIOPHYSIOLOGY • Fascial compartments allover 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 DXCompartmentSyndrome DX • 5 P’s • Pain • Paresthesia • pallor • Pulseless • Poikilothermia • FORGET THE LAST 3 • Call your lawyer
- 94. Compartment syndrome: DXCompartmentsyndrome: DX PAIN out of proportion to the clinical picture Acronym POP
- 95. Compartment syndrome DXCompartmentsyndrome DX • Pain with passive motion of joint distal to compartment • Also active range
- 96. Compartment syndrome DXCompartmentsyndrome DX • Paresthesias • Occurs later, usually prior to irreversible changes
- 97. Compartment syndrome: DXCompartmentsyndrome: DX • Interesting fact • 50 % patients with compartment > 30 had 2 point discrimination > 1 cm in median nerve distribution
- 98. Compartment syndrome DXCompartmentsyndrome DX • Compartment may feel tense • Like wood
- 99. Compartment syndrome: TestsCompartmentsyndrome: 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 RXCompartmentSyndrome 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 RXCompartmentSyndrome 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-surgeoncan doWhat the non-surgeon can do • DIAGNOSIS • AWARENESS OF DIAGNOSIS
- 104. What the non-surgeoncan 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-surgeoncan 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 CSECTIONSIMILAR 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 CITYSURGEONSREVENGE ON CITY SURGEONS • Keep the surgical techniques book available • Telephone consultation with orthopedic surgeon • Cut and send
- 109. Compartment Syndrome RXCompartmentSyndrome 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 trueabout 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 injuryAcuteBoutonniere 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 AvulsionDistalBiceps 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 syndromeAcutecompartment 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 lesionAStener 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 MSKinjuriesSoft Tissue MSK injuries • QUESTON PERIOD
Editor's Notes
- #87 ma