Musculoskeletal and soft-tissue emergencies

Essentials

1
The mechanism of injury and biomechanics predict the soft-tissue damage caused.
2
Soft-tissue injuries can be as debilitating and painful as fractures in the same area, and may take longer to heal.
3
The so-called ‘minor injury’ can be associated with significant and prolonged morbidity that could be permanent if managed incorrectly. Adopting a careful, consistent approach that considers potential pitfalls is important to patient outcome.
4
Exclude potentially serious causes of back pain by assessing for ‘red flags’ in every patient presenting with this complaint.

Common Causes of Soft-Tissue Injuries

All injuries have a soft-tissue component. The simplest way of dividing their causes is into ‘acute’ (specific event that exceeds tissue tolerance) and ‘chronic’ (repetitive minor damage in excess of ability to heal). Both types may be further subdivided by the tissue affected (bone, tendon, muscle, etc.).

Acute soft-tissue trauma can also be subdivided by the mechanism:

Penetrating:
- puncture versus incised
- solid object versus fluid stream (high pressure hose, etc.).
Blunt:
- crush injury±laceration
- shear/degloving (open or closed).

Many of the types of trauma above are covered in other chapters.

General evaluation of a soft-tissue injury

Assessment

History

Obtain a history of:

the nature of the injury: when, where and how it was sustained with specific attention to the forces involved, especially any potential crush or shear injury with devitalized tissue
the possibility of a foreign body, wound contamination and/or damage to deeper structures
patient function pre and post injury
pain associated with the injury, including time course, nature and aggravating factors
co-morbidities and drug therapy
allergies and tetanus immunization status.

Examination

The extent of any nerve damage should be determined before using local anaesthetic.

Examination should potentially be delayed until after an x-ray if a radiopaque foreign body (metal or glass) is suspected, after giving analgesia.

Tendon damage may be best elucidated after adequate analgesia is obtained so the wound can be adequately explored.

Puncture Injury

Management

Refer immediately to the appropriate surgical team all high-pressure gun injuries, such as from grease, paint or oil where the skin has been broken, even if no damage is apparent initially. They require extensive wound debridement and tissue plane cleaning, however innocuous they may seem.

Otherwise, clean the wound and evaluate the need for tetanus prophylaxis and antibiotics. A puncture wound to the sole of the foot will require exploration if it has occurred through the sole of footwear, or potentially has a foreign body.

Prophylactic antibiotics are controversial. If prophylaxis is chosen, give amoxicillin/clavulanate 875/125 mg bd for 5 days, add pseudomonal cover (e.g. ciprofloxacin 500 mg bd) if it is an at-risk injury such as through footwear. As these wounds are at a high risk of infection, instruct the patient to return if increasing pain, redness or swelling occurs.

Acute Mechanical Overload Injuries

These include fractures, ligament sprains, muscle strains or tears, and tendon ruptures. Many are covered in Section 4 .

See Table 14.4.1 for a classification system for ligamentous sprains.

Table 14.4.1

Classification of ligament sprains/muscle strains

Grade	Features
I	Small number of fibres injured, pain on loading, but no laxity or loss of strength
II	Significant number of fibres injured, with laxity and/or weakness and pain on loading
III	Complete tear with gross laxity and no strength

Management

General principles

The initial management principles are the same for both ligament sprains and muscular strains. This includes protection, rest, ice, compression and elevation (PRICE) with analgesia, usually a combination of paracetamol 1 g orally qid, plus a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen 400 mg orally tds (in the absence of NSAID-sensitive asthma, peptic ulcer disease and renal impairment).

Ligament sprain

Ligament sprains that are grade I or II (see Table 14.4.1 ) are managed with a protective brace or strapping and reduction in, but not cessation of, physical activity. Consider immobilizing grade III sprains with a splint or plaster of Paris (POP) cast and/or operative repair if there is gross instability and warn the patient that he or she can take up to 3 months or longer to heal. This is of particular relevance to the manual labourer and high-level athlete. Proprioception retraining at physiotherapy has been shown to prevent recurrence in the long term (>1 year) but not mid-term (6 to 9 months) in lateral ankle sprains.

Muscle strain

Muscle strains require initial PRICE to minimize bruising and haematoma formation followed by a graded return to activity. Physiotherapy may aid in return of function and prevent re-injury.

Assess the functional limitations imposed by these injuries, particularly in patients who live alone and/or who are elderly and infirm, as loss of independence is likely. A complete muscle tear, especially in an active individual, may benefit from operative repair following referral to an orthopaedic specialist. Consider the need for community services, respite care or admission for those who are initially unable to care for themselves.

Tendon rupture

Evaluation

Acute rupture of the supraspinatus tendon (see Chapter 4.1 ), long head of biceps and Achilles tendon (see Chapter 4.11 ) are the most common serious tendon injuries that present to an emergency department (ED). Injury may be secondary to an acute event or chronic overload that is often asymptomatic until a tear occurs, and the extent of the rupture may be partial or complete.

Management

Treatment is aimed at the earliest return to normal function, with the least likelihood of recurrence. Refer a complete tear, particularly in active people, for orthopaedic surgery for consideration of operative repair. Manage partial tears conservatively, but they too may have a better outcome if repaired surgically, depending on local hospital practice and surgical availability.

One exception is a long head of biceps tendon tear, which usually results in a mostly cosmetic defect—the ‘Popeye’ sign. However, in highly active people or those with associated rotator cuff pathology surgical repair is often indicated.

An ultrasound can confirm the diagnosis. Magnetic resonance imaging (MRI) is equally or more sensitive and specific depending on which tendons are being imaged, although it is much less readily available.

Pretibial Laceration

These are most common in elderly patients, often from trivial trauma that tears a flap of skin, particularly if taking steroids. Ask about general mobility and safety issues at home.

Management

The majority of these wounds will heal with conservative management. Clean the wound, remove blood clots, trim obviously necrotic tissue and unfurl the rolled edges of the wound to determine actual skin loss. Refer the patient immediately for consideration of debridement +/− early skin grafting if there is large skin loss, gross contamination, major haematoma or marked skin retraction preventing alignment of the skin edges.

Otherwise, lay the flap back over the wound and hold in place with adhesive skin-closure strips (Steristrips). Then cover the wound with a non-adhesive dressing, and apply a firm crêpe bandage and instruct the patient to keep the leg elevated when not walking. Determine the need for tetanus immunization or booster.

Arrange follow-up with either outpatient wound services, or if unavailable, to the ED in 5 days for review and a dressing change, or earlier if blood or serum has seeped through the wound dressing, known as ‘strike-through’, which increases the risk of secondary infection.

Degloving Injury

Evaluation

Degloving injuries are caused by either a shearing or traction force on the skin, causing it to be torn from its underlying capillary blood supply. When the skin actually peels off it leaves an obvious exposed open injury, or the skin may remain intact causing a closed injury.

A closed degloving injury is much harder to diagnose with up to one-third thought to be missed at the time of initial trauma. It occurs most commonly in the hip, thigh or pelvic region and usually in the setting of high energy trauma. The clinical exam is often complicated by underlying bony injuries. The most consistent finding is soft fluctuance and/or hypermobility of the skin. Decreased cutaneous sensation is often but not always present. The best diagnosis is on imaging; CT is reasonable but MRI is the preferred imaging modality. Pain may or may not be prominent and/or may relate to an underlying bony injury.

Management

Arrange specialist assessment and admission for all degloving injuries by the appropriate surgical team, usually plastic and/or orthopaedic surgery. Keep any degloved skin, as it may be used as a skin graft.

Do not be tempted simply to replace the skin into its original position and hold it there with sutures or adhesive skin-closure strips (Steri-Strips), as this is inadequate. Degloving injuries are also a high-risk wound for tetanus.

Chronic Overuse (Overload) Injuries

Chronic overuse injuries develop wherever tissue microtrauma occurs at a rate that exceeds the body’s natural ability to heal. Few require emergency treatment, but general knowledge of these conditions is valuable to advise patients on cause and management.

Classification

Bony overuse injuries follow a continuum from pain on activity only, through local tenderness to pain at rest, with loss of function. Many will have led to a stress fracture by the time of presentation to an ED.

Other overuse injuries are classified by the tissue type and the extent of injury and are often best diagnosed by the timing of the pain in relation to physical activity. They are further classified by the presence or absence of inflammation. See Table 14.4.2 for a classification of chronic overuse syndromes.

Table 14.4.2

Classification of chronic overuse syndromes

Grade	Symptom
I	Pain after activity
II	Pain early on and after activity; activity not limited
III	Pain throughout activity, which is limited
IV	Pain at rest

Management

Most chronic overuse injuries are managed with a decrease in activity and NSAIDs, though their use in stress fractures is controversial. Arrange referral to a physiotherapist or specialty physician, such as sports or performing arts physician, as appropriate. Tendon-related injuries may benefit from a steroid injection, which should only be performed by doctors trained in the technique (orthopaedic surgeons, rheumatologists, sports physicians or some ED doctors).

Specific chronic overuse injuries that require more extensive management are summarized in Table 14.4.3 .

Table 14.4.3

Stress fractures which require active specialist management

Injury	Associated with	Symptoms	X-ray	Other imaging	Management
Pars interarticularis	Gymnasts, ballet dancers, fast bowlers	Unilateral low back pain, worse on extension	Pars # often seen	CT or MRI definitive, XR+Bone scan alternative option	Avoiding hyper extension for 6/52, consider brace for 6–12/52; core stability retraining once healed
Femoral neck (see Chapter 4.7 )	Athletes/military increased activity	Vague thigh/groin pain with loading	Often normal	Bone scan or MRI, CT less sensitive	If <50% of bone fractured, decrease activity, if >50% ORIF
Femoral shaft	Dancers	Vague thigh/knee pain with loading	# Usually visible	CT or bone scan	Lateral cortex—ORIF, medial cortex (much rarer) non-weightbearing 6/52
Anterior cortex of mid-tibia (see Chapter 4.10 )	Distance runners, ballet dancers	Progressive anterior leg pain with activity	Anterior # line, thickened cortex	Bone scan? Non-union versus recent injury	Decrease activity, intermedullary nail if progresses
Talus (see Chapter 4.12 )	Repeated falls/jumping from height	Foot/ankle pain worse with weightbearing	Usually normal	Bone scan, CT or MRI	6/52 non-weightbearing in POP
Navicular	Increased running/marching	Vague midfoot pain with point tenderness over navicular	May show #	Bone scan, CT or MRI	6–8/52 non-weightbearing, ORIF if fails to heal
Base 2nd metatarsal	Ballet dancers	Forefoot pain on exercise	# Usually visible	Bone scan, CT or MRI but usually not needed	Non-weightbearing on crutches for 4–6/52
Base 5th metatarsal (see Chapter 4.12 )	Ballet dancers	Midfoot pain with activity	# Usually visible	Bone scan, CT or MRI but usually not needed	Non-weightbearing with POP for 6/52 or direct ORIF as often fail to heal
Sesamoid bone of hallux	Increased running/marching	Forefoot pain, tender/swelling over ball of foot	Often hard to interpret	Bone scan or MRI	6/52 Non-weightbearing with crutches then orthotics to correct biomechanics

CT , Computed tomography; MRI , magnetic resonance imaging; ORIF , open reduction internal fixation; POP , plaster of Paris; XR , x-ray; 6/52, 6 weeks.

Non-Arthritic Joint and Soft-Tissue Disorders

General management of non-arthritic joint and soft-tissue disorders

Joint pain, swelling and tenderness mimicking arthritis may be due to inflammation of periarticular structures. Most patients can be treated with NSAIDs, such as ibuprofen 200 to 400 mg orally tds or naproxen 250 mg orally bd and/or with paracetamol.

Underlying or secondary true arthritis also may be present and complicate the presentation. Joint aspiration is indicated to rule out a septic arthritis and, when this is suspected, follow local guidelines as to who performs it. Refer the patient in whom a septic joint has been excluded back to the general practitioner (GP) or outpatients unless mobility is so significantly affected that he or she requires admission.

Do not perform a steroid injection in the ED, as complications, such as septic arthritis and joint destruction, do occur. This is best left to the specialist who undertakes long-term care. Some of the more common presentations include the following.

Torticollis (‘wry neck’)

Diagnosis

Torticollis is abnormal unilateral neck muscle spasm, resulting in the head being held in a bent or twisted position. The aim of the history and examination is to exclude a serious underlying cause such as local sepsis/abscess, recent trauma, cervical disc prolapse, acute drug dystonia, raised intracranial pressure, or even a carotid artery dissection.

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