Adult Medical-Surgical Nursing Musculo-skeletal Module: Sports/ Soft Tissue Injuries

Musculo-skeletal Trauma/ Common Sports Injuries  Contusion: soft tissue bruising  Strain: pulled muscle  Sprain: damaged joint ligaments  Dislocation: joint out of position  Subluxation: partial dislocation  Tendonitis: inflammation of tendons  Ruptured tendon  Torn meniscus  Fracture (see lecture)

Soft Tissue Injuries: Pathophysiology  Sudden strain, twisting, tearing or dislocation (trauma) leads to:  Inflammatory response to neutralise, control and wall-off the injured area and prepare for repair

Soft Tissue Injuries: Inflammatory Response  Mediated by chemicals, histamine, kinins (bradykinin), prostaglandin from injured tissue. Leads to:  Vasodilation/ increased blood supply  Increased vascular permeability and infiltration of leucocytes for phagocytosis of debris/ pathogens  Fibrinogen to fibrin for clotting (to wall-off/ prevent systemic infection)

Inflammatory Response: Clinical Effects  The clinical effects of the increased blood flow and vascular permeability are:  Pain (congestion of the area/ kinins)  Heat  Swelling  Redness  Loss of function

 Soft Tissue Injury/ Sprain

Sprain: Description  Damage to the ligaments of a joint as a result of sudden abnormal or amplified, extended movement

Soft Tissue Injury/ Sprain: Clinical Manifestations  Pain on movement  Pain at rest  Swelling  Bruising  Restricted range of movement from pain and oedema  General symptoms: nausea, faintness at time of injury

Soft Tissue Injury/ Sprain: Diagnosis  Usually diagnosed by patient history and clinical picture

Soft Tissue Injury/ Sprain: Management  Rest  Ice  Compression  Elevation  Analgesia and anti-inflammatory drugs  Gradual exercise with rehabilitation

 Joint Dislocation/ Subluxation

Joint Dislocation: Description  Damage with displacement of a joint as a result of sudden abnormal or amplified, extended movement  Involves muscles, ligaments, tendons

Joint Dislocation: Clinical Manifestations  Severe acute pain on slightest movement with faintness, nausea  Dull ache or pain at rest  Deformity of joint  Possible swelling or bruising  Reduced range of movement  Possible numbness, tingling, coolness, discoloration of affected limb (neurovascular involvement)

Joint Dislocation: Diagnosis  Patient history  Clinical picture  Xray  MRI for soft tissue injury

Joint Dislocation: Management  Immobilisation  Reduction under anaesthesia (displaced parts into position)  Support in correct position (bandages, slings, splints)  Analgesia, anti-inflammatory drugs, muscle relaxants  Observe neurovascular status  Gradual rehabilitation exercises

 Injury to Tendons

Common Injury to Tendons: Classification  Ruptured Achilles tendon (calf)  Rotator Cuff tears (acromioclavicular joint/ shoulder): acute injury or chronic joint stress  Tendonitis: “Tennis Elbow” (affects wrist grasp also)

 Ruptured Achilles Tendon

Ruptured Achilles Tendon: Description  A sudden acute tear of the Achilles tendon usually in a sports activity

Ruptured Achilles Tendon: Clinical Manifestations  Sudden acute, extreme pain in calf area  Inability to plantar flex  Shock, nausea, faintness

Ruptured Achilles Tendon: Diagnosis  Patient history  Clinical Picture  Xray: exclude bony injury

Ruptured Achilles Tendon: Management  Immediate analgesia  Prompt repair under anaesthesia  Immobilise with plaster cast  Elevate and rest  Observe circulation to toes  Static quads exercises: improve circulation/ muscle tone  Progressive physio: promotes ankle strength/ movement until full weight-bearing

 Rotator Cuff Tears:

Rotator Cuff Tears: Description  Acute or chronic shoulder tendon injury

Rotator Cuff Tears: Clinical Manifestations  Painful shoulder joint  Limited range of movement  Some joint dysfunction/ muscle weakness  Unable to perform over the head activities  Night pain: unable to sleep on affected side  Acromioclavicular joint is tender

Rotator Cuff Tears: Diagnosis  Patient history  Clinical picture  Xray (joint structure)  Arthrography  MRI (soft tissue/ extent of rotator cuff tear)

Rotator Cuff Tears: Management  Anti-inflammatory drugs  Rest and modify activity  Local corticosteroid injection (joint)  Progressive strengthening exercises  Surgery if unresolved: arthroscopic debridement or tendon repair  Immobilisation of shoulder up to 4 weeks then physio

 “Tennis Elbow”: Tendonitis

“Tennis Elbow”/ Tendonitis: Description  Excessive repetitive activities of the forearm causing inflammation and minor tears of the tendons (affecting elbow and wrist grasp)  A chronic painful condition

“Tennis Elbow”/ Tendonitis: Clinical Manifestations  Pain which characteristically radiates down the dorsal surface of the forearm  Weakened grasp  Diagnosis from history and clinical picture

“Tennis Elbow”/ Tendonitis: Management  Rest and avoid aggravating activity  Anti-inflammatory drugs  Immobilisation in splint may be helpful  Corticosteroid injection locally if other measures not effective  Rehabilitation exercises to gradually stretch the tendons  Support strap to prevent recurrence

 Meniscal Injury

Meniscal Injury (Torn Meniscus): Description  The menisci are the 2 semi-lunar cartilages of the knee joint attached to the head of tibia allowing articulation with the femur

Meniscal Injury: Aetiology  Injury and tearing away from the tibia occurs with:  Excessive twisting of the knee  Repetitive squatting and impact  Mostly sports injury

Meniscal Injury: Pathophysiology  Loose cartilage in knee joint slips between tibia and femur interfering with movement  Inflammatory process set up in response

Meniscal Injury (Knee Joint): Clinical Manifestations  Inability to fully extend the leg  If happens during walking/ running: leg “gives way”. It is painful and unexpected  Clicking of the knee on extension/ weight-bearing  Locking of the knee  Inflammation and swelling/ effusion of knee joint (torn cartilage)

Meniscal Injury (Knee Joint): Diagnosis  Patient history and clinical picture

Meniscal Injury (Knee Joint): Management  Conservative management:  Immobilisation of the knee  Crutches and modification of activities  Anti-inflammatory medications  If symptoms persist:  Arthroscopy to determine damage and surgery: Meniscectomy (removal of torn cartilage)

Meniscectomy: Post-operative Care  Pressure dressing applied to knee to prevent effusion  Immobilisation with splint  Rest with leg elevated  Static quads/straight-leg-raising exercises  If effusion occurs (painful):  Aspirated to relieve pressure  Usually able to resume normal activities in days

Sports/ Soft Tissue Injuries: Nursing Considerations  Emotional/ psychological support throughout care  Stay with patient at time of injury  Ensure prompt analgesia/ comfort  Observe vital signs/ neurovascular function of affected limb  Hand-washing and aseptic technique  Encourage appropriate exercises