1
Q
WHAT ARE SOFT TISSUE INJURIES
A
- TENDONS- CONNECT MUSCLE TO BONE
- MUSCLE- CONTRACT TO PRODUCE MOVEMENT (THINGS THAT GIVE YOU POWER)
- LIGAMENTS- FIBROUS BAND OF TISSUE THAT CONNECTS BONE TO BONE.
- MENISCUS- A FIBROCARTILAGINOUS STRUCTURE THAT REDUCES FRICTIONS BETWEEN JOINTS.
- BURSA- FLUID FILLED SAC THAT REDUCES FRICTION BETWEEN MUSCLES AND BONES. (MAY BECOME INFLAMED AND CAUSE PAIN)
2
Q
WHAT ARE THE DIFFERENT TYPES OF JOINTS?
A
- BALL AND SOCKET (SHOULDER)
2.PIVOT (ULNA/RADIAL, TIBIA/FIBIA) - PLANE (WRIST, ANKLE AND VERTEBRAE)
4.SADDLE (THUMB)
5.HINGE(ELBOW,KNEE, DIGITS)
6.ELLIPSOID (WRIST, BASE OF SKULL AND ANKLE)
3
Q
TYPES OF MINOR INJURIES:
A
- SPRAIN- TENDON OR LIGAMNET DAMAGE
- STRAIN- ISSUE UE WITH MUSCLE
3.RUPTURE OF A LIGAMNET/TENDON- IT’S TORN (LONG HEALING PROCESS)
4.FRACTURE- BREAK OF A BONE
5.SUBLUXATION- PARTIAL DISLOCATION
6.DISLOCATION- COMMON IN SHOULDER & KNEE
7.WOUNDS
8.ULCERS
9.BURNS
4
Q
SOFT TISSUE INJURY CLASSIFICATION:
A
- GRADE 1: THERE IS DAMAGE TO A SMALL AMOUNT OF FIBRES, VISIBLE LOCALISED SWELLING. GOOD RANGE OF MOVEMENT, RELIEVED WITH SELF CARE
-GRADE 2: DUE TO MORE OF A SEVERE MECHANISM, LARGER NUMBER OF FIBRES ARE DAMAGED,OFTEN BLEEDING/HEMATOMA, LAXITY- EXCESS MOVEMENT IN THE LIGAMENT. - GRADE 3: A BIG DEFORMITY, COMPLETE LOSS OF FUNCTION AND YOU MAY SEE PALPABLE GAPS, REFFER TO ORTHOPAEDICS
5
Q
TYPES OF FRACTURES
A
- GREENSTICK- COMMON IN PAEDS
- AVULSION
- NORMAL
- GREENSTICK
- TRANSVERSE
- OBLIQUE
- SPIRAL
-COMMINUTED - IMPACTED
- FISSURE
6
Q
TENDON PAIN
A
- NO CLEAR HISTORY
- NOT ONE MECHHANISM OF HX THAT OFTEN SUGGESTS INJURY
- LOCALISED TO THE. JOINT AS THAT’S WHERE THE TENDON IS.
- TENDONITIS - INFLAMMATION OF THE TENDON, OCCURS QUITE QUICKLY (E.G. KICKING FOOTBALL FOR A PROLONGED TIME WHEN YOU DO NOT USUALLY, AND ANKLE GETS SWOLLEN)
*TENDINOSIS- SLOWER PROCESS, TISSUES CHANGE, MINOR TEARS IN TISSUE, HEALING PROCESS CAUSES SCARS AND COLLAGEN TISSUES TO BUILD UP. OFTEN DUE TO REPETITIVE STRAIN INJURIES (TENNSI ELBOW).
7
Q
CARTILAGE PROBLEMS
A
- PAINLESS
- LOCKING AFFECT IN KNEE DUE TO MENISCUS
-OFTEN DUE TO INJURY OR WEAR AND TEAR
8
Q
LIGAMENT PROBLEMS
A
- DIRECT OR INDIRECT FORCE
- SIGN OF INJURY (GOING OVER ANKLE)
- MAY BE JOINT INSTABILITY
- MAY HAVE LAXITY
- PT MAY BE SYMPTOMATIC FOR 6-8WKS
9
Q
STEPS FOR PHYSICAL EXAMINATION
A
- INTRODUCTION
- ASK FOR CONSENT!
- INSPECTION/LOOK
-PALPATION/FEEL
-MOVEMENT/MOVE
-JOINT ABOVE, JOINT BELOW
10
Q
INSPECTION
A
LOOK FOR SWEADES
Swelling
Wounds
Exudate- liquid pus
Atrophy- muscle wastage
Deformities
Erythema- redness
Scars
11
Q
PALPATION
A
- Palpate the hurry bit last!!!
- Look for signs of discomfort
- Assess for neurovascular compromise- radial pulses, distal sensation, temperature
- feel underlying structures
12
Q
MOVEMENT
A
- Feel for crepitus- don’t illicit it
- ACTIVE
- PASSIVE
- RESISTED MOVEMENT
13
Q
PLAN:
A
-If we are concerned and the pt is presenting with red flags, neurovascular compromise or deformities, take them to ED!
-minor injury unit
- Self care worsening care advice e.g. If they’ve hit their head and mechanism is not that serious, give them warning signs; if you experience any nausea or vomiting, dizziness, experience loss of consciousness, go to ED or call back 999.
14
Q
Assessment:
A
- assessment needs to be thorough
- injury could affect daily living
- ask about hand dominancy in hx
-look, feel, move-active, passive, resisted
15
Q
How to assess for vascular compromise:
A
- check pulse
- cap refill
- temperature
- colour
- sensation (touch all 3 nerves)
16
Q
Kumars test
A
- assesses for motor compromise
- Dorsal flexion of the wrist tests the radial nerve
- thumb to ulna tests the medial nerve
- ulnar nerve, medial nerve, radial nerve
17
Q
Joint above-neck
A
- look: any deformities like kyphosis, scoliosis
-feel the c spine for any pain, tenderness, atrophy - movement: flexion, extension, rotation
18
Q
Shoulder anatomy:
A
- start from the sternum, then across the clavicle which joins the sternum via the sternoclavicular joint.
- the acromion process joins the clavicle via the acromioclavicular, then the glenohumeral joint
- coracoid process is the bony bit that sticks out that’s not attached to anything.
*4 joints: sternoclavicular, acromioclavicular, glenohumeral, scapulothoracic
19
Q
Shoulder landmarks:
A
- ANTERIOR:
. Sternoclavicular joint
. Clavicle
. Acromioclavicular (AC) joint
. Coracoid Process - POSTERIOR:
. Spine and boarders of the scapula
-HUMERAL:
.Head of humerus
.Greater and lesser tubercule
. Biceptial groove
. Deltoid muscle
20
Q
What are the 4 rotator cuff muscles?
A
Rotator cuff helps the muscle with joint stability. Easily injured through tendon, muscle or bone injuries.
1.Supraspinatus- abduction
* usually occurs due to painting their ceiling
2. Infraspinatus- external rotation
3. Teres Minor- external rotation
4. Subscapularis- internal rotation
21
Q
What are the movements of the shoulder?
A
- extension
- flexion
- internal & external rotation
- abduction & aduction
22
Q
Painful arc test
A
- You can assess what tendons/muscles are damaged by how far the pt can go abduct their arm.
- If pt experiences severe pain when abducting their arm from:
1. 0-20 degrees, it’s likely a full thickness tear of the supraspinatus
2. 20-40 degrees axillary nerve damage (deltoid is not working)
3. 40-60 degrees adhesive capsuilitus (frozen shoulder)
4. 60-120- impingement of the supraspinatus/ sabacromial pain
5. 120-180 degrees, they have acromioclavicular pain
23
Q
How can you assess for neurovascular compromise in shoulder injury/pain?
A
- perform regimental badge sign on both arms and if there is pain, pt has axillary nerve damage which is a red flag and needs to go ED.
- This assesses motor and sensation
24
Q
What are common shoulder injuries?
A
TRAUMA
- Fractures
- Dislocation
NON TRAUMA:
- rotator cuff tear
- impingement
-Adhesive capsulitis (frozen shoulder)
25
What’s osteomyelitis?
Infection of the bone, be cautious with open wounds
26
What are the 4 tests for rotator cuff tear?
1. Drop arm/painful arc
2. Jobes/ empty can test
3. Teres minor and infraspinatus test
4.lift arm test
27
What is adhesive capsulitis?
- AKA Frozen shoulder
- Unknown cause
- Pts with diabetes have a higher incidence
- Comes on progressively with pain, stiffness, reduced ROM, pt is unable to sleep on that side
- Quite rare
28
What 3 bones does the elbow consist of?
- Distal humerus
- Proximal radius
- Proximal ulna
29
What are 3 joints of the elbow?
- Ulnotrochlear
- Radiocapitellar
- Radioulnar
30
What would you palpate in an elbow assessment?
- Lateral epicondyle
- Medial epicondylitis
- Radius
- Ulna
- Humerus & shoulder (joint above)
31
What ligament allows for movement of the radius?
- angular ligament
32
What are common elbow injuries?
- Pulled elbow
- Lateral epicondyle (tennis elbow)
- Medial epicondyle (Golfer’s elbow)
- Olecranon bursitis
- Fracture
- Dislocation
33
Pulled elbow
- Common in kids when their swung from both arms.
- This occurs as the angular ligament is not fully developed and it slips out of the radius.
- Pain on supination’
- May be caused by a fall
- In over 5’s, the annular LIGAMNET is thicker and stronger and prevents subluxation (partial dislocation).
34
Lateral epicondylitis
- Result of repetitive strain injury (form of tendinitis)
- AKA tennis elbow
- Common injury with hx preceding it
- Overuse strain on insertion of muscles at the lateral epicondyle
- Perform the mills test to investigate for this.
35
Medial epicondylitis
- AKA golfer’s elbow
- repetitive strain injury due to pressure from playing golf for a long time.
- Overuse strain on insertion of muscles at the medial epicondyle
- Tear in the tendon
36
Olecranon Bursitis
- Repeated minor trauma from leaning on the elbow
- Single blow to the elbow= bleeding into bursa
- If the limb becomes hot to touch and red, think SEPSIS, check pts NEWS2– RED FLAG!
- Pt may require antibiotics and might need it drained if it’s large.
- Corticoid steroids may be used on recurrent cases
37
Radial head fracture
- May be the result of a FOOSH due to the force exerted onto the outstretched limb.
- Often tenderness, decreased ROM and pain
- Perform a shoulder and elbow exam too
38
Supracondylar Fracture
- Common in paeds
- Distal head of the ulnar
- If its s shaped there’s a deformity and the fracture has moved.
* If you’re querying a fracture, get pt to perform active movement. If that’s fine get them to do passive and if it’s still painful, it’s likely a fracture, do not perform resisted if suspecting a fracture!!
39
What are the 8 carpal bones?
1. Scaphoid
8. Trapezium
7. Trapezoid
6. Capitate
5. Hamate
2. Lunate
3. Triquetrum
4. Pisiform
* So Long To Pinky Here Comes The Thumb
40
Anatomy of the hand:
- Distal head of the radius (thumb side)
- 8 carpal bones
- Metacarpals
- Metacarpal phalangeal joint (knuckles)
- 3 parts to the phalanges: Proximal, Middle and distal phalange
41
Common injuries of the hand:
- Fractures
- Laceration
- Carpal tunnel
Assessment:
- HX
- look
- Feel
- Move
-Colour
- Perfusion
- Sensation & Motor
- Neurovascular compromise-kumar
42
Radial head fracture
- Flexion fracture of radius (smiths fracture)
- Extension fracture (colles fracture)- most common FOOSH injury
- GREENSTICK fractures- common in paeds
43
Scaphoid fracture
- Really debilitating, can cause disability in the thumb if it’s missed.
- FOOSH mechanism
-May not heal properly if left to heal on its own, could develop avascular necrosis due to retrograde blood supply from radial artery.
* Anatomical snuffbox- if it hurts on PALPATION, pt may have a scaphoid fracture
* Telescoping of the thumb- pressing the metacarpal into the thumb
44
Carpal tunnel syndrome
- Where the medial nerve becomes trapped- tendons and nerves become inflamed causing compression of the median nerve.
- May be the result of trauma, arthritis, swelling, fracture, pregnancy diabetes
- Pt experiences pain & numbness
- Chronic condition
*Phalens test- upside down prayer sign (hold it there for a min) and see if pt feels pins n needles.
* Tinnel tap test should illicit pins and needles and sensation if the medial nerve is trapped.
45
Finger Joints
- Flexor tendons bend the fingers (palmar aspect of hand) pronate hand
- Extensor tendons - straighten the fingers (dorsal aspect)
* In an extensor tendon injury, the affected inter is unable to extend and stays flexed.
- Distal interphalangael joints (DIP)
- Proximal interphalangeal joints (PIP)
46
Flexor tendons
- Flexor digitorium profundus
* Profundus goes from the finger to the tip, it’s profund
- Flexor digitorium superficialis
* Joins to the middle phalange
47
Flexor tendons examination
- Flexor Digitorium Profundus
* To assess, isolate the DIP by stabilising the middle phalanx and get pt to bend their finger.
- Flexor Digitorium Superficialis
* Isolate other fingers and ask the pt to flex the PIP
48
Jersey finger
- Common rugby injury when someone grabs another players jersey forcing the finger backwards.
- Causes an avulsion fracture of the flexor Digitorium fundus
* Avulsion fracture is where piece of the bone off is ripped from the joint.
- surgery is needed asap
49
Extensor injuries
- More common
- Mallet finger
-Boutonnière
- Swan neck deformity
50
Mallet finger
- Extensor injury
- Forced hyperflexion
- May occur when trying to catch a baseball and the ball forces the finger forwards, causing an injury to the flexor.
- May occur when changing bed sheets.
* If there’s blood under the nail, it may be an open fracture, usually immobilised in a splint and heels itself.
51
Boutonnière deformity
- Disruption of the PIP central slip
- There has been volar slip of the lateral bands
- Can be caused by a laceration or an inflammatory weakening.
- PIP has been flexed whilst the DIP has been hyperextended.
52
Swan neck deformity
- Opposite of boutinneres
- May be caused by rheumatoid arthritis or untreated mallet finger
- Hyperextension of the PIP and flexion of the DIP
- There is damage to the tendon or weakening at the DIP.
53
Finger Fractures
- Punch injuries- pts who have been in fights who have been bitten need to go UCC as they need tetanus and antibiotics, they may need surgery to irrigate it.
- Boxers fracture- 5th metacarpal, very common from punching someone or something
54
Digital nerves
- Branches of the radial, medial and ulna all go to digital nerves.
- To test digital nerves, other than assessing sensation , use a bic pen
* Digital nerves stimulate sweat production, if there is no sweat and the pen glides, potentially the digital nerves have become damaged.
- Good for avocado injuries.
55
What do flexor tendons do?
- Bend the fingers
56
What do extensor tendons do?
- Straighten the fingers
PMMH
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