Week 3: Care of Musculoskeletal Injuries

What is the Ottawa Ankle Rule?

Indications to xray

if there is pain near the malleoli AND

bone tenderness is present along posterior edge OR

patient unable to bear weight atleast 4 steps at time of injury

What does RICE stand for?

Rest

Ice

Compression

Elevation

What does MEAT stand for?

Movement

Exercise

Analgesics

Treatment

What does LOVE stand for?

Load

Optimise

Vascularisation

Exercise

What does HARM stand for?

Heat

Alcohol

Running

Massage

Why is Ice controversial to use for soft tissue injuries?

Delays the natural healing process rather than speed it up.

What is a Fascia Iliaca Compartment Block (FICB)?

Medical procedure where local anaesthetic is injected into the fascia iliaca.

Spreads to nerves in that area, blocking out pain.

Typically used for NOFs

What is soft tissue?

Skin, deep fascia

Muscle, muscle-tendon unit, teno-periosteal attachments

Joints, ligaments, capsule/synovial membrane, fibrocartilage, fat pad, bursae.

What is hard tissue?

Bone

Cartilage

Longer healing times

What are special tissues and organs?

Brains, nerve, eyes, nose, sinuses, larynx, teeth.

What is stress?

Amount of load placed on a tissue.

What is strain?

The relative change in length associated with the stress applied.

What is a stress/strain curve?

Curve that is specific for a material and expressses the amount of strain (E, deformation) that material undergoes under increasing amount of stress (sigma, force)

What is a Grade 1 soft tissue tear?

Mild injury involving tearing of only a few fibres

What is a Grade 2 soft tissue tear?

Moderate injury involving a considerable portion of fibres

What is a Grade 3 soft tissue tear?

Complete tear or rupture

What are the three stages of soft tissue repair?

Acute Inflammatory (2-3 days)

Repair (2-3 day to 2-6 weeks)

Remodelling (3 weeks - 6-12 months)

What is the acute inflammatory repair stage?

Initial damage and damage control.

Vascular changes

Systematic mediators

Capillaries often damaged

Swelling, redness, heat, pain, loss of function

What is the repair (reconstructive/proliferative) repair stage?

Clean up and reconstruction

Destruction of clot by macrophages

Creates collagen

Fibroblasts

Regeneration from surrounding cells

Wound contraction

What is the remodelling repair stage?

Rehabilitation/return to function

Reorientation of collagen fibrils and muscle cells

Collagen maturation

Capillaries disappear

Scar formation

What are the pros of immobilisation?

Provides protection to injured area

Allows inflammatory phase to occur

Avoids re-injury

What are the cons of immobilisation?

Muscle: Atrophy

Loss of thickness

Decreased bone density

Increased strain

Disorganisation

What are the basic principles of injury management?

Minimise extent of initial damage

Reduce pain/inflammation

Promote healing

Maintain/restore flexibility

Functional rehab

What influences rehabilitation?

Extent of injury

Individual healing

Patients age/health

Previous function

Goals

Committment

What is a lateral ankle ligament sprain?

Most common sporting injury (100,000 ED presentations each year)

What history taking should be done for an ankle injury?

Establish mechanism

Any sounds?

Ability to weightbear

Degree of pain

Initial management

What physical exam should be done for an acute ankle injury?

Gait

Active range of motion v passive range of motion

Palpation

What does the Ottawa ankle rule include?

Pain at malleious OR

Bone tenderness posterior edge of the distal 6cm of tibia

OR

Bone tenderness at the posterior edge of the distal 6cm of fibula

OR

Inability to weight bear for 4 steps both immediately and after exam.

What does the purpose of the Ottawa ankle rule?

Is an xray needed.

Is needed if there is any pain and one of the criterias.

What is a Grade 1 Lateral Ankle Ligament Sprain?

Nil instability on testing

What is a Grade 2 Lateral Ankle Ligament Sprain?

Mild/Moderate instability

What is a Grade 3 Lateral Ankle Ligament Sprain?

Major instability

What is the management for an ankle injury?

RICER

Is an XRAY needed? (Ottawa ankle rule)

Gait aids

Restoration of ROM

Strength

Proprioception

What are common structures damaged in knee injuries?

Medial meniscal tear

MCL sprain

AC sprain

Lateral meniscus tear

Articular cartilage injury

PCL sprain

Patella dislocation

What is considered for knee injuries regarding location of pain?

Poorly localised: Pain with cruciate ligament injuries

Well localised: Pain with collateral ligament injuries

Severity of pain not always correlated with injury severity

What can be told about knee injuries regarding swelling?

Immediate swelling (0-2 hours): Haemathrosis

Delayed swelling (6-24 hours): Effusion

What is the Ottawa Knee rule?

age >55 or

What is an ACL rupture?

Common in sport injuries.

Women more than men

- Can often be caused by running-sudden change of direction

- Landing with knee in hyperextension

- Landing and twisting

What is a Medial Collateral Ligament (MCL)

Valgus force to partially flexed knee

Classified from grade 1 to 3.

Distal MCL injuries, longer recovery time

What is a Lateral Collateral Ligament (LCL)

Rarer than MCL

Often in conjuction with PCL tears

Grade 1 to 3

What are Meniscal Injuries

Gradual or delayed swelling

Locking

Restriction in ROM

Pain on weight-bearing

Joint line tenderness, joint effusion

May need surgery, may need rehab

What is a patellar dislocation

Patella moves out of groove.

Immediate pain, swelling

Dislocation usually reduces spontaneously with knee extension.

What are the indications for Patella Relocation?

Between 12 and 40

Isolated dislocation

Low mechanism injury

Obviously displaced patella, knee pain, inability to flex or extend

What are the contraindications for Patella Relocation?

Younger than 12

Over 40

High mechanism

Severe knee swelling, or presence of an osteochondral fracture

How is a patella relocated?

Gently extend knee while applying medial direct force to the patella.

Check stability of knee join.

Assess range of motion and conduct neurovascular.

PATELLA DISLOCATION CPG: What is involved in Reduction

Neurovasc pre and post

Pain relief

Reduction

PATELLA DISLOCATION CPG: What is involved in Referral

If patella relocated

Able to weight bear

Neurovasc normal

IF FENT GIVEN: Normal vitals, adult supervision for 4hrs.

Bandage, self care, safety netting.

GP follow up or timely imaging if first dislocation

PATELLA DISLOCATION CPG: What is involved in Transport

Not relocated

No weight bearing

Neurovasc abnormal

Complications or significant pain

IF FENT GIVEN: Abnormal vitals, drowsy, no supervision

Transport

What is a Glenohumeral Dislocations?

Complete absence of continuity between the humeral head and the glenoid

Why is an XRAy required for a Glenohumeral Dislocations?

To eliminate bony damage to glenoid or HH

To eliminate avulsion fracture greater tuberosity

What is a Bankart Lesions?

Displaced fracture of the glenoid rim after anterior glenohumeral dislocation

ANTERIOR SHOULDER DISLOCATION CPG: When is Reduction indicated?

No signs of fracture

Low MOI

Arm not abducted at right angles to body

Duration since dislocation

ANTERIOR SHOULDER DISLOCATION CPG: What is involved in Reduction

Pain relief

Then BHM and SAM

What is a BHM reduction?

Consent and explain procedure

Sit patient, bandage wrists together

Bend knee on same side of dislocation.

Patient puts hands around knee

Lean back until arms are straight and let the neck hang backwards

Shrug shoulders

Hold position

What is a SAM reduction?

Consent and explain procedure

Lay patient down

Using unaffected arm, grasp other arm

Slowly lift outwards and upwards above head

Hold position

ANTERIOR SHOULDER DISLOCATION CPG: What is involved in Referral

Shoulder relocated

Patient can touch opposite shoulder

Reduction in pain

Normal Nurovasc

IF FENT GIVEN: Normal vitals, alert, adult supervision for 4hrs.

Sling, self care, safety netting, GP follow up

ANTERIOR SHOULDER DISLOCATION CPG: What is involved in Transport

Remains deformed

Cannot touch opposite shoulder

Abnormal neurovasc

Complications

Ongoing severe pain

IF FENT GIVEN: Abnormal vitals, drowsy, no supervision.

Transport

What are the types of Lower back pain?

Specific (Serious pathophys)

Non specific (85% of the time)

What are some causes for lower back pain?

Cancer, spinal stenosis, posture, muscle strain, herniation

What are red flags of back pain?

TUNAFISH

- Trauma

- Unexplained weight loss

- Neurological symptoms

- Age over 50

- Fever

- IV drug use

- Steroid use

- History of cancer

LOWER BACK PAIN CPG: Who is included in this guideline?

Undiagnosed

LOWER BACK PAIN CPG: What are high risk factors?

Non isolated pain

Suspected caude equine syndrome

Suspected fracture

Cancer

Infection

LOWER BACK PAIN CPG: What is considered Mild, what is done?

Mobile, minor pain.

Provide self care (rest), paracetamol, health information sheet.

LOWER BACK PAIN CPG: What is considered Moderate, what is done?

Limited mobility, no high risk.

Pain relief, VVED referral

LOWER BACK PAIN CPG: What is considered Severe, what is done?

Unable to mobilise, high risk criteria, large amounts of analgesia needed.

Pain relief

Transport

What is done for a pelvic fracture?

Pelvic pain, haemodynamic instability, ACS

Pain relief

Pelvic splint

Tranport

What is done for a neck of femur fracture?

Limb shortening, external rotation, pain in hip or groin

Pain relief and anatomical splinting

What is done for a limb or digit fracture?

Pain relief

CT - 6, formable or anatomical splint

Reduction/realignment

Irrigation

What is done for soft tissue injuries?

Ottawa knee or ankle rule

Pain relief

Safety netting

Timely follow up if fracture more likely (24hrs)

OR

GP follow up (2-3 days)