Simon C. Mears
John H. Wilckens
Ronald P. Byank
Injuries to the musculoskeletal system involve muscles, tendons, ligaments, joints, and bones. Such injuries are a frequent reason for presentation to an ambulatory care office. According to the National Health Ambulatory Medical Care Survey, an estimated 104 million injury-related visits (36.7 visits per 100 persons per year) were made to physicians in 2002 (1). The lifetime risk of acute fracture has been estimated to be as high as the risk of coronary artery disease (2). Musculoskeletal injuries, including lacerations, bruises, sprains, tears, dislocations, and fractures, range from benign to fatal, from those that will heal with no treatment to those that require complex, specialized care. Patients frequently present to general clinicians seeking professional advice and treatment for orthopedic problems that develop after participation in sporting activities. Most of the injuries associated with exercise also may occur in nonexercising people via falls, missteps, overactivity, or minor motor vehicle accidents. The ambulatory medicine clinician must treat these injuries appropriately, know when additional imaging is required, and know when a referral for specialist care is needed.
This chapter provides an explanation of the spectrum of musculoskeletal injuries and a rational approach for addressing these problems.
Patient Evaluation
History
The clinician must obtain a thorough history and perform a complete physical examination of the injured patient to determine the diagnosis and treatment. A primary concern is to rule out a musculoskeletal emergency that requires immediate evaluation and/or referral, such as septic arthritis, acute myelopathy or spinal cord compression, deep venous thrombosis, anterior compartment syndrome, or tumor (3). The American College of Rheumatology has identified “red warning flags” in the history that suggest more urgent evaluation: a history of trauma sufficient to cause mechanical derangement, a hot swollen joint, constitutional symptoms, focal or diffuse weakness, neurogenic pain patterns, or claudication pain patterns (Table 68.1).
As with any painful condition, an appropriate history includes onset, duration, quality and character of pain, and ameliorating and provoking factors (4). Injuries can present as acute or chronic problems, and determining the time course is important. Examples of questions regarding the temporal events surrounding the injury are the following:
Pain from musculoskeletal injuries is rated with a visual analog pain score from 0 to 10. The clinician should determine what activities make the pain worse or better.
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TABLE 68.1 Warning Signs That Suggest the Need for Urgent Evaluation of Musculoskeletal Problems |
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Overuse injuries are common, and patients should be questioned with these injuries in mind. Overuse injuries occur when a new activity is started or when the amount or level of activity is increased. For example, runners frequently face injury when they increase their weekly mileage or when they start more intense workouts, such as timed sprints. Young women are particularly vulnerable and should be questioned with regard to eating habits and menstrual cycles because eating disorders typically lead to irregular periods, which may result in osteoporosis and stress fractures. Overuse injuries also occur from repetitive activities around the home or at work. Patients should be asked about working conditions and positions. Long hours at a computer without the use of appropriate ergonomic aids may lead to injury of the upper extremity or neck.
Patients with osteoporosis are susceptible to stress fractures that, left untreated, can become displaced. Osteoporotic fractures may result from overuse or from a minor falls that was forgotten. It may be difficult to diagnose correctly a fracture in a patient with osteoporosis because of distracting conditions such as arthritis or conditions such as Alzheimer disease that prevent good history taking.
After the history of the injury is obtained, a more extensive patient history is necessary, including medical conditions, previous injuries, and risk factors for poor healing, osteoporosis, and fractures. A detailed social history is instrumental in planning management and assessing prognosis. Cigarette smoking, for example, leads to a higher rate of nonunion and infection after operative treatment (5). It is important to determine what medicines a patient is taking and what underlying disorders the patient has, both of which may interact with medicines commonly prescribed for injury.
Physical Examination
The area of injury should be examined thoroughly. The clinician should uncover the area, examine the skin, and compare the injured limb to the contralateral side so that evidence of muscle wasting or deformity can be determined. It is important that both sides of the body are uncovered and examined for comparison. Skin injury or contusions should be noted, and the area of tenderness should be examined. The exact point of pain must be located. The one-finger test is helpful in localizing pain. The patient is asked to point to the area of maximal tenderness with one finger only; use of a whole hand or pointing to multiple spots does not count. Limbs should be evaluated for deformity. Individual joints are checked for range of motion and stability. The joint above and below the injured area should be examined. For shoulder injuries, the cervical spine should be examined. For lower leg pain, the lumbar spine should be evaluated. A neurologic examination should include a bilateral limb evaluation of sensation, muscular strength, and deep tendon reflexes. Vascular evaluation should include palpation of pulses and assessment for varicosities, venous stasis, and common effects of arterial vascular disease, such as loss of hair.
Imaging Evaluation
Imaging evaluation of the musculoskeletal system includes many modalities, such as plain radiography, computed tomography, magnetic resonance imaging (MRI), ultrasound, bone scanning, and arteriography. These studies often can help establish a diagnosis or narrow the differential diagnosis. Selection of the most valuable imaging technique is important. If one is uncertain about which imaging evaluation to order, a radiologist or an orthopedist can be consulted by telephone.
Plain radiographs are the most commonly used imaging technique in the evaluation of musculoskeletal injuries. In evaluating a patient with injury, one should request
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radiographs if the patient has any bony tenderness, swelling, or deformity. Standard radiographs should include anteroposterior and lateral views because some fractures are not seen in one plane; other views (e.g., stress views) also can be helpful. For instance, a stress view, obtained with the joint of interest in varus (distal bone bent toward midline) and/or valgus (distal bone bent away from midline) stress, can show abnormal openings or joint instability secondary to ligamentous injury (6). A useful principle is to examine by radiograph the bones above and below any bone or joint injury.
Use of computed tomography, MRI, ultrasound, bone scanning, and invasive imaging tests should be limited to situations where the clinician suspects a specific diagnosis for which the imaging study would alter the treatment plan. These secondary imaging techniques usually are considered for investigating an abnormality seen on plain films, and each offers qualitatively different information. Computed tomography defines bony anatomy well in cross section. MRI is especially valuable for assessing soft tissues and bone marrow. Ultrasound is valuable for studying soft-tissue lesions that are thought to be cystic or to contain other collections of fluid. Bone scans define the extent of many skeletal lesions, such as metastatic or infectious diseases, and suggest whether or not the lesion is metabolically active. Arteriograms and venograms use contrast dye to define or rule out abnormalities of a vessel. In general, use of these secondary imaging modalities should be deferred to an orthopedic surgeon, vascular surgeon, or sports medicine specialist. The specialist often can obtain the same information by a more focused physical examination and ultimately spare the patient additional discomfort, expense, and time. For example, in one study of meniscal injuries using arthroscopy as the gold standard, the accuracy of the clinical examination performed by orthopedists was 82% for medial meniscal tears, 76% for lateral meniscal tears, and 99% for complete tears of the anterior cruciate ligament, whereas the accuracy of MRI was 75%, 69%, and 98%, respectively (7).
Types of Injury
Skin Injury
Injuries to the skin include abrasions and lacerations. Wounds should be cleaned and examined. A determination must be made as to whether the wound is superficial or deep. Superficial lacerations can be repaired with suture after subcutaneous injection with local anesthetic. A dissolvable suture is used in children, and a nondissolvable, nonreactive monofilament suture (such as nylon) is used in adults. Deep injuries may damage underlying nerves, blood vessels, tendons, or muscle. A thorough examination is needed to detect these injuries to the limb. A plain radiograph should be used to search for possible debris in the laceration. Referral to an orthopedist is needed for neurovascular or tendinous injury or for retained debris in a laceration.
Wounds to any tissue (except bone) heal through similar mechanisms. The healing response begins with a coagulation phase. A laceration opens blood vessels, causing bleeding. The tissues react with vasoconstriction and activation of clotting pathways. After the initial coagulation, the tissue becomes inflamed through activation of multiple humoral mediators. These substances lead to vasodilation and the attraction of polymorphonuclear neutrophils. Proteases are produced to digest necrotic debris, and tissue macrophages then act to remove necrotic debris and begin to form channels through the blood clot for future capillary formation. In the granulation phase, several important responses occur: fibroblasts begin to produce proteogylcans and collagen, angiogenesis occurs as capillaries begin to bud, epithelialization occurs at the wound edges, and the wound begins to contract through the activation of myofibroblasts. In the final stage of wound healing, a scar forms that gradually matures over time. Only rarely does skin regain its full strength or elasticity, in contrast to bone, which can regain its original strength (8).
Muscle Injury
Muscles are composed of repeating units of muscle cells or sarcomeres that have a contractile machinery composed of actin and myosin. By activation of the neuromuscular junction from motoneurons, sarcomeres contract to produce shortening (contraction) of the muscle, which leads to joint motion. Muscle tearing occurs when a muscle is overlengthened acutely, leading to damage to the sarcomere and the connective tissues between cells in the muscle (9). Bleeding occurs into the muscle, with accompanying inflammation and pain. Muscle fibers may tear from an acute stretch during activity or from a force applied to a muscle, such as a physical blow from a baseball bat. A muscle may sustain a complete tear or a partial tear called a strain. Muscle strains are common injuries frequently sustained during sporting activity. The history often reveals a clear sensation of muscle “grab” or “pull.” The injury often prevents additional participation in the physical activity, and weight-bearing of the extremity usually is painful. On physical examination of a patient with a muscle strain, there is swelling, tenderness, and worsening pain with stretching of the involved muscle during active or passive range of motion. The hamstring muscle is the most common muscle injured by sporting activity, and it typically occurs with explosive muscular activity such as sprinting or jumping.
Muscle tears and strains should be treated with rest and avoidance of activity. The clinician should institute strategies to reduce inflammation. The RICE protocol, which
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consists of rest (period of no to partial weight-bearing), ice (applied for 10–15 minutes several times per day), compression (with an elastic bandage [ACE wrap]), and elevation, is used for relieving symptoms and expediting recovery. After the acute pain and swelling have been reduced, the patient should resume activity gradually. Activities must be performed at a level that does not cause renewed pain. A regimen of stretching and gradual strengthening of the muscle should be followed until the patient can resume full activity (10).
An important component in the treatment and prevention of strains is adequate conditioning. Stretching and warmups are believed to increase muscle flexibility and ability to extend when stressed during exercise. To be effective, stretching exercises, when performed, should be done correctly. Movements should be slow and graduated to allow for slow stretching of muscle fibers; bouncing is especially to be avoided because it will increase the risk of injury. The position of ultimate, reasonably comfortable stretch should be held for 15 to 20 seconds and then repeated (Fig. 68.1). To minimize the chance of injury, any rigorous sport or exercise activity should follow a slow, gentle warmup, and, on completion, be followed by a cool-down period (e.g., a slow jog after running). The cool-down allows gradual recovery from peripheral vasodilation that occurs during exercise and removal of lactate from muscles. After a period of recovery from a strain (usually 2–4 weeks or until symptoms and signs are fully cleared), strengthening exercises of the strained muscle group will help decrease the likelihood of injury recurrence.
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FIGURE 68.1. Stretching exercises. A: Stretch the Achilles tendon by leaning forward with the feet flat and placed at least 4 ft from the wall. B: Stretch the hamstring and gastrocnemius muscle groups by elevating the leg and bending forward as much as possible. C:Stretch the hamstring and back muscles by slowly bending forward to touch the toes while keeping the knees extended. D: Stretch the adductor muscles by gradually spreading the legs as far apart as possible while placing the fingers on the floor for support. With all stretching exercises, the motion should be slow and steady; bouncing should be avoided. |
The ambulatory clinician should be aware of two sequelae after muscle tears: compartment syndrome and heterotopic ossification. Hematoma after an injury may result in an acute increase in pressure within the muscle. The amount of swelling may be restricted by the thick fascia that surrounds the muscle or group of muscles. Nerves and blood vessels also pass through the fascial compartments and may be affected by high pressures. This rapid increase in pressure is termed compartment syndrome and is a surgical emergency. Compartment syndrome may lead to muscle and nerve necrosis in the affected limb with permanent sequelae if not treated. Even simple muscle tears, such as rupture of the gastrocnemius or biceps, may lead to compartment syndrome (11). Any patient with severe pain and swelling should be considered at risk for compartment syndrome and emergently referred to an emergency room and orthopedic surgeon. Pain out of proportion to the injury is the best clinical sign of compartment syndrome. Particular care must be taken with patients who are unreliable or are not capable of reporting pain accurately. Diagnosis involves the use of a pressure monitor to determine compartment pressures. Most surgeons recommend emergent fasciotomy when pressure is elevated to within 30 mm Hg of the patient's diastolic pressure (12).
Another complication of muscle injury is heterotopic ossification, or myositis ossificans. Muscle injury and hematoma may lead to calcification within the muscle. Although rare, this complication may cause substantial disability and lead to a large area of bone formation within the muscle. In some cases, excision may be required because of pain or stiffness (13).
Tendon Injury
Tendons, the fibrous ends of muscles that insert into the bone, are composed of cells called fibrocytes and a matrix of glycosaminoglycans and strong type I collagen bundles. The force of a muscle is directed through the tendon to cause movement of the bone at a joint. Tendons can be ruptured acutely by the application of too much force or subacutely through chronic injury.
An acute tendon injury may result in an acute tendon rupture. After rupture, the muscle will not function to move the associated joint. Typical areas for tendon rupture include the Achilles tendon in the heel and the quadriceps tendon in the knee. Most acute tendon ruptures require surgical repair to allow for early motion of the joint and healing. Operative repair typically involves suture repair
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of the ruptured ends of the tendon. Results of tendon repair are favorable, although the joint may lose motion and strength, especially if physical therapy efforts are not followed postoperatively (14,15). Some patients, such as those with rheumatoid arthritis, taking chronic steroids, or who received intratendinous injections of corticosteroids, are vulnerable to tendon tears, and rupture may occur with no inciting traumatic event (16).
Overuse injuries to tendons are common and are thought to result in a condition termed tendinopathy. Pathologically, tendinopathy results in fibrotic changes to the tendon fibers. Chronic pain in the tendon can be hard to cure. Initial treatment includes nonoperative measures such as muscle strengthening and stretching. If these efforts fail, surgery to resect the area of altered tendon may be required. Less invasive options, including percutaneous tendinopathy and ultrasound treatments, have been developed (17).
Ligament Injury
Ligaments, fibrous structures around a joint that give it stability, are composed of fibroblasts, type I and type III collagen, elastin, and proteoglycans. Each joint in the body has different requirements for stability and mobility. The shape of the joint and the position and strength of its surrounding ligaments are responsible for the stability and mobility of the particular joint. For example, the sacroiliac joints in the pelvis have little motion and are extremely stable. The sacroiliac joints have a very broad surface and strong constraining ligaments. In contrast, the shoulder is a ball-and-socket joint designed to maximize the motion of the arm. The ligaments of the shoulder provide far less constraint and allow for motion in all directions.
Ligaments are injured when excessive or sudden stress is placed on a joint. Ligament injuries range from a stretching type injury called asprain to full disruption. The amount of force required to injure a ligament depends on the stability of the individual joint. A low-energy twisting motion may have enough force to disrupt the ligaments of a mobile joint, such as the shoulder, but not those in more stable joints, such as the sacroiliac joints of the pelvis. A higher-energy injury, such as that from a car accident, could cause rupture of both the anterior pubis symphysis and the posterior sacroiliac ligaments in the front and back of the sacroiliac joint, resulting in a pelvic ring disruption. As the energy imparted from an injury increases, multiple ligaments around a joint may be injured. The joint may dislocate, and the bones within the joint may sustain fractures.
When a ligament is stretched or sprained, the joint becomes painful and swollen. Point tenderness is present over the sprained ligament, but the joint is stable to examination and is not dislocated. Radiographs reveal no fractures or dislocations. MRI reveals edema in the ligament. Sprains are graded on a three-level continuum (Table 68.2).
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TABLE 68.2 Severity of Ligamentous Sprains |
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Grade I sprains entail stretching or microscopic tearing of the ligament with no clinical evidence of joint instability or laxity on physical examination. These minor injuries usually resolve in a few days to weeks with minor symptomatic treatment, such as brief periods of immobilization, the RICE protocol, progressive weight-bearing, and use as tolerated.
Grade II sprains are partial tears of the ligament with mild to moderate instability and laxity of the joint. To prevent additional injury in a patient with grade II sprains, the affected area should be immobilized. The best modality for immobilization depends on patient reliability and the extent of injury. Options include prefabricated braces (either soft or hard), moon boots (large ski-boot–like shoes), and a fabricated cast. If the lower extremity is involved, a brief period (usually 1–2 weeks, although the length of time required varies) of no to partial weight-bearing with crutches is followed by gradual, progressive weight-bearing as tolerated. Even when progressive weight-bearing is allowed after 2 weeks, some patients may still require the use of a brace or splint for added protection and stability. Nonsteroidal anti-inflammatory drugs to control pain and inflammation and physical therapy for muscle strengthening and preservation of function can expedite the clinical course.
Grade III sprains are complete ruptures of the ligament(s) and present with obvious signs of joint instability and laxity. If the injury is in the lower extremity, a patient often is unable to bear weight. Radiographs usually show lack of congruency of the articular surfaces of the bones of the joint or opening of the joint with varus or valgus stress (see Imaging Evaluation section). In a patient with such an injury, the area should be immobilized with a splint, and the patient should be referred to an orthopedic surgeon. The orthopedist may consider prolonged immobilization,
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ligament repair, or reconstruction. Occasionally, depending on the severity of the injury and the effect of the problem on the patient's baseline function, these options also may be applicable to patients with severe grade II injuries or those for whom nonoperative methods have failed.
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FIGURE 68.2. Ligament injury. A: Radiograph showing rupture of the syndesmotic ligament in the ankle. B: Screws are used to reduce the syndesmotic injury and allow for healing of the ligaments. |
In high-energy injuries, multiple ligaments are disrupted, leading to joint instability and dislocation. Acute dislocations should be referred to an emergency room for treatment. Joint dislocations should be treated emergently by reduction of the joint under local or general anesthesia. Unreduced dislocations may lead to long-term morbidity. A dislocated hip, for example, puts pressure on the blood vessels to the femoral head. The longer the hip remains dislocated, the higher the risk is of femoral head osteonecrosis secondary to disruption of the blood supply.
Reduction of a joint typically requires sedation and an analgesic. Aspiration of the joint to remove the hematoma, combined with intra-articular injection of local anesthetic, may provide enough pain control to allow for joint reduction. However, reduction of a joint with powerful muscles, such as the shoulder or hip, may require a general anesthetic. After joint reduction, radiographs are obtained to assess for joint stability and fracture. MRI or computed tomography scans may be indicated to delineate small fractures, damage to the articular cartilage, or ligaments that may require repair. If a joint is stable after reduction, care includes gentle range of motion of the joint followed by a more formal physical therapy program to regain motion and strength.
In some cases, joint dislocation may lead to chronic joint instability. Chronically unstable joints have damaged ligaments and may dislocate with very little force. Treatment of chronic dislocation involves reconstruction of the weakened or disrupted ligaments to provide a stable joint and allow activity (18). The patterns of injury that lead to chronic joint instability can be identified by an orthopedic surgeon. Injuries such as a syndesmotic ligament rupture in the ankle are best treated with internal fixation to prevent chronic joint instability (Fig. 68.2). In some cases, surgical repair of a ligament may not lead to a good outcome, and reconstruction is required. An example is rupture of the anterior cruciate ligament in the knee. Results of repair are poor, and reconstruction with an autograft or an allograft tendon will provide joint stability.
Cartilage Injury
Injury to the joint may cause damage to the joint's cartilaginous surface of the joint and intra-articular structures such as the labrum or meniscus. All joints have a smooth surface covering made of articular cartilage. Cartilage is attached firmly to the underlying bone and composed of several layers. The upper layers are packed with glycosaminoglycans. This surface is resistant to wear and has slick mechanical properties. Some joints have a rim of cartilaginous tissue that provides support to the joint. In the shoulder and hip, this rim of tissue is called the labrum, and it is located around the cup of the joint. In the knee and wrist, this tissue is called the meniscus. The labrum and meniscus are important to the joint in terms of shock absorption and articular cartilage protection. Patients present after an injury with pain, tenderness, and
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joint effusion. Physical examination must rule out ligamentous injury and joint instability. Diagnosis is made with MRI. In the hip and shoulder, enhancement of the MRI with intra-articular injection of gadolinium may be necessary to reveal a labral tear. Nonoperative treatment, including rest, ice, and anti-inflammatory medicines, is the first line of therapy for cartilage injuries. Treatment should be based on MRI findings and on the age and activity of the patient. Operative intervention may be necessary to unlock a joint or to repair or débride the torn cartilage or meniscus (19,20).
Bone Injury
Bones are thought of as inert and lifeless; however, little could be further from the truth. Bones not only provide stability to the body; they also serve as a calcium bank for the body. Bones are made of a stout exterior or cortex and spongy interior or marrow. The cortex is composed of a lamellar structure with precisely aligned type I collagen fibers. Hydroxyapatite crystals deposited within the collagen provide a high tensile strength.
Bone exists in a continual process of breakdown and renewal. In healthy individuals, this balance is established precisely. The collagen structure is permeated with tiny canals that are populated with cells. Osteoclasts are multinucleated cells that function to resorb bone. Osteoblasts are cells of mesenchymal origin that function to produce new bone matrix or osteoid. Because of bone's continued regenerative ability, its healing is unlike that of other tissues. Bones have the ability to heal without the formation of scar tissue (21). If the fine balance between bone breakdown and renewal is disrupted, changes to the bone occur. In osteoporosis, the rate of bone disruption is higher than the rate of renewal, leading to weaker bones. Bones respond by widening their diameter and developing thinner cortices. A wider, thinner bone has some strength but is more brittle and more susceptible to fracture (22) (see Chapter 103).
When an applied load exceeds a bone's mechanical properties, fracture occurs. Fractures can be displaced or nondisplaced, and they can occur acutely from an injury or subacutely from continued or repetitive stresses. Repetitive stresses cause microfractures that may lead to a nondisplaced fracture, termed a stress fracture.
Stress fractures can occur in young, healthy patients and in older patients with osteoporosis. In the young, healthy patient, a stress fracture occurs as the result of newly applied, sustained loads across the bone, as in the army recruit who must run or march long distances in basic training. In this situation, the bone is not capable of responding to these suddenly applied stresses. The patient notices point tenderness over the area of fracture that worsens with activity. Unchanged activity levels may lead to a displaced fracture. In the osteoporotic patient, the bone becomes so weakened that the simple forces of daily living may lead to progressive microfractures, and stress fractures may develop with no warning signs.
Plain radiographs may not identify stress fractures, and it is important to continue the evaluation to treat a nondisplaced fracture before it becomes displaced. A bone scan can reveal the stress fracture, but it may not do so acutely, that is, within the first 48 hours after injury. An MRI scan shows edema in the bone and is the most sensitive test for stress fracture (23).
Fractures from an acute injury are diagnosed with plain radiographs. Two orthogonal views must be obtained in all cases. Nondisplaced fractures generally are treated with immobilization and reduced weight-bearing. In the acute setting, the joint should be splinted, and the patient should be referred for orthopedic evaluation. The length and amount of restriction is based on the fracture's location and stability or its likelihood for displacement. Some fractures, such as a nondisplaced distal fibula fracture, are stable, and weight-bearing and early motion are safe. Other fractures, such as a nondisplaced femoral neck fracture, may require additional stabilization, such as screws and weight-bearing limitations until healing, to avoid displacement, which could lead to nonunion or osteonecrosis that might require hip replacement (arthroplasty).
Displaced fractures may require immobilization or operative treatment, depending on several factors, including whether the bone has penetrated the skin and the precise location and pattern of the fracture. Fractures are called open when the bone pierces the skin. Open fractures may range in severity from a small pinhole through the skin to devastating crush injuries that are massively contaminated. The greater the force to the bone, the more energy must be absorbed by the body, leading to more extensive soft-tissue destruction and more damage to the bone. Patients with displaced fractures should be managed according to Advanced Trauma Life Support guidelines (24).
It is important that the clinician be able to distinguish an open fracture from a closed one. If a wound is present around the area of fracture, a careful examination of the skin must be performed. It is possible for an abrasion of the skin to occur over a broken bone. If, however, a wound around a fractured bone does not stop bleeding or oozing, the fracture should be considered open. Open fractures should be treated initially with removal of gross contamination and gentle washing with sterile saline. A povidone iodine (Betadine) dressing then should be applied and the limb should be splinted. The patient should be transferred emergently to an emergency department for prompt evaluation by an orthopedic surgeon. Open fractures are treated definitively with surgical débridement and fixation. Surgical débridement of the wound allows for decontamination and lessens the risk of infection and osteomyelitis.
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In addition to examining for open wounds, the clinician should note the neurologic and vascular condition of the limb. Pulses should be palpated. If pulses cannot be palpated, a Doppler device should be used to check the pulses. A pulseless limb is a true surgical emergency that will lead to loss of limb if not treated within several hours of injury. The physician also should examine the limb for evidence of compartment syndrome. Of note, open fractures are more susceptible than are closed fractures to compartment syndrome because open fractures typically are caused by high-energy trauma, which leads to more muscle injury and swelling. An orthopedic surgeon should evaluate emergently for evidence of massive swelling or decreasing neurologic status.
The position of the fracture and the exact location determine later treatment by the orthopedic surgeon. Displaced fractures that occur in the shaft or diaphysis of the bone may be treated with or without surgery. The goals of fracture treatment are to restore limb length, correct limb rotation, and obtain bony healing. Nonoperative treatment of shaft fractures includes the use of casts and fracture braces. Other displaced fractures require internal or external fixation. Shaft fractures often can be stabilized with minimally invasive techniques and indirect fracture reduction. Intramedullary nailing has been shown to have a >90% chance of healing fractures of the femoral shaft (25).
Fractures that enter the joint or intra-articular fractures require referral to an orthopedic surgeon. Intra-articular fractures cause damage to the articular cartilage, leading to joint incongruity and posttraumatic arthritis (26). The greater the fracture displacement, the higher the rate is of arthritis. Most intra-articular fractures are treated operatively for two reasons: (a) to facilitate joint reduction and maintain of that position for healing, and (b) to allow early motion of within the joint. Without fixation, the joint must be immobilized, which leads to stiffness and dysfunction (27,28).
General Approach to Patient and Referral Guidelines
Most patients with musculoskeletal complaints or injuries can be divided readily into one of two categories: acute or chronic musculoskeletal problems. Acute problems include those related to trauma, recent overuse syndromes, sprains and strains, stress fractures, joint infections, recent peripheral nerve or nerve root impingement, and compartment syndrome. Chronic problems include osteoarthritis, chronic overuse syndromes, bursitis, bony infections, bone and soft-tissue tumors, chronic peripheral nerve or nerve root problems, and claudication. A precise time distinction between acute and chronic problems cannot be made. Nevertheless, it is a common presumption for one to consider any problem that persists for more than 3 months as a chronic condition. There can always be an element of the acute with chronic injury; for example, one may have a recent meniscal injury in the setting of knee osteoarthritis, or an athletic injury may be the presenting complaint that brings attention to a joint affected by rheumatoid arthritis.
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TABLE 68.3 Guidelines for Referral of Patients with Musculoskeletal Problems to a Specialist |
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In managed care environments, general clinicians are faced with the challenge of being the “gatekeepers” for referrals to specialists and other allied health professionals. Therefore, knowing when and when not to refer a patient is important. Table 68.3 provides general criteria for referral to an orthopedic surgeon. Problems such as major fractures, open injuries, dislocations, compartment syndromes, and septic joint infections require immediate referral to an orthopedist for evaluation and treatment. Red warning flags of a serious problem in the history and physical examination of a patient include evidence of severe trauma, night pain, fever, chills, joint instability, gross deformity, locked joints, and marked restriction of joint motion. Patients with one or more of these manifestations should be referred urgently to a specialist. On the other hand, the general clinician can comfortably treat, with the nonoperative methods addressed above, most other musculoskeletal injuries. If such measures fail after a reasonable period, then referral to an orthopedist is appropriate.
Specific References*
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.
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