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Common Musculoskeletal Disorders

Oct 03, 20249 min read

Inflammatory Musculoskeletal Disorders

  1. Synovitis: inflammation of the synovial lining of the joint. These present as red, warm, swollen joints.
  2. Tendonitis/Tendinitis: inflammation of a tendon.
  3. Bursitis: inflammation of the bursa (friction pads around the body)
  • Treatment:
    • Rest the extremity and apply intermittent ice or heat.
    • NSAIDs may be used.
    • Arthroscopic Synovectomy: removal of the swollen synovial lining.

Traumatic Musculoskeletal Conditions

(The section on Fractures is separated into its own section)

  1. Contusions: a soft tissue injury from blunt force (blow, kick, fall). Many small blood vessels rupture and bleed into soft tissues, which result in ecchymosis/bruising. A hematoma forms, leaving a characteristic “black and blue” appearance. They may be minor, severe, isolated, or in conjunction with additional injuries, like in a fracture.
    • Signs and Symptoms: pain, swelling, discoloration, potentially limited ROM, and weakness or stiffness in injured muscles.
    • Management: these often self-resolve within 1 to 2 weeks, with severe contusions taking longer.
    • Typing:
      • Subcutaneous Contusions: bruising beneath the skin. These begin as a pinkish red color, then a bluish color, then yellowish, before finally fading.
      • Intramuscular Contusions: bruising within the underlying muscle. These last longer than subcutaneous bruises, potentially for months.
      • Periosteal Contusions: bruising of the periosteum; a “bone bruise”. These are the most severe and painful type of bruise.
  2. Strain: a “muscle pull”. These are caused by improper use, overuse, overstretching, or excessive stress. These are microscopic incomplete muscle tears with some bleeding into the tissue.
    • Signs and Symptoms: soreness, sudden pain, local tenderness upon muscle use.
    • Typing:
      • First Degree Strain: a mild stretching of the muscle or tendon with no loss of ROM. Signs and symptoms include gradual onset of palpation-induced tenderness and mild muscle spasm.
      • Second Degree Strain: moderate stretching and/or partial tearing of muscle or tendon. Signs and symptoms include acute pain during precipitating events followed by tenderness at the site with increased pain upon passive ROM, edema, significant muscle spasms, and ecchymosis.
      • Third Degree Strain: severe muscle or tendon stretching with rupturing and complete tearing of involved tissue. Immediate pain described as “tearing, snapping, or burning”, muscle spasm, ecchymosis, edema, and loss of function.
        • An x-ray should be obtained to rule out bone injury, because an avulsion fracture (where a tendon pulls a bone fragment from a bone) may be associated. X-rays is not useful for assessing soft tissue injury.
        • MRI can reveal soft tissue injury (tendon injury).
  3. Sprain: an injury to the ligaments surrounding a joint, often caused by a twisting motion or hyperextension. Blood vessels rupture and edema occurs. The anterior talofibular ligament of the ankle, as well as the knees and wrists are the most vulnerable areas of the body.
    • Signs and Symptoms: joint instability (as ligaments serve as stabilizers and support), tenderness and pain upon movement. Pain increases for the first two to three hours after the injury as swelling and bleeding increases pressure on the affected area.
    • An x-ray is required to rule out bone injury (avulsion fracture)
    • Grading:
      • Grade I: stretching or slight tearing of the ligaments, mild and localized hematoma, and manifestations of mild pain, edema, and local tenderness.
      • Grade II: partial ligament tears, and manifestations of increased pain with motion, edema, tenderness, joint instability, ecchymosis, and partial loss of normal joint function.
      • Grade III: complete ligament tearing or rupturing, which may also result in an avulsion fracture. Symptoms include severe pain, edema, tenderness, ecchymosis, and abnormal joint motion.
  • Management for Contusions, Strains, and Sprains: RICE, Surgical Repair, Immobilization - Rest to prevent additional injury and promote healing - Ice: moist/dry cold applied intermittently 20 to 30 minutes (to avoid cold damage) during the first 24 to 72 hours after injury to induce vasoconstriction, reducing bleeding, edema, and discomfort. - After 48 hours (acute phase), heat may be applied to relieve muscle spasm, promote vasodilation, absorption, and repair. - Compression via elastic compression bandages controls bleeding, reduces edema, and provides support for the injured tissues. - Elevation at or above the level of the heart reduces swelling. - Surgical Repair if muscle fibers are torn and ligaments are disrupted. - Immobilization via splints, braces, or casts may be required for up to 3 weeks in severe strains or sprains to maintain joint stability. - NSAIDs may be given for pain management. - Monitor the neurovascular status of the injured extremity frequently: q15m for the first 1 to 2 hours after injury, then at lesser intervals until stable. Acute compartment syndrome is suggested by decreased sensation or increased pain levels, and should be reported to the primary provider immediately. - Passive and active exercises is began as early as possible, depending on the severity.
  1. Joint Dislocation: a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact. If caused by trauma (traumatic dislocation), it is considered an orthopedic emergency because of the associated joint structures (blood vessels, nerves) are distorted and severely stressed. If not immediately treated, avascular necrosis (AVN) and nerve palsy may occur.
    • Signs and Symptoms: acute pain, a change in the contour of the joint, a change in the length of an extremity, a loss of normal mobility, and a change in the axis of the dislocated bones.
    • Diagnostic Examination: an x-ray confirms the diagnosis and any associated fractures.
    • One of the most common form of dislocation is a radial head dislocation when the forearms of children are pulled.
    • A subluxation is a partial dislocation, where some contact is still maintained.
    • Medical Management focuses on (1) avoiding neurovascular complications and (2) reducing the joint as atraumatically as possible.
      • Immobilization at the scene, during transport, and at the hospital. This may be done with splints, casts, or traction.
      • Reduction of the dislocation to return proper anatomic position, to preserve joint function.
      • Analgesia, Muscle Relaxants, and Anesthesia may be used to facilitate closed reduction.
      • Neurovascular status is assessed every 15 minutes until stable.
      • Active and Passive Movement is initiated gently and progressively as soon as the joint is stable. The joint remains supported during movement.
    • Nursing Management: focus on frequent assessment, activities, and danger signs and symptoms e.g. increasing pain (even while on analgesia), numbness or tingling (paresthesia), and increased edema in the extremity. These indicate acute compartment syndrome, which may lead to disability or loss of the extremity.

Structural Defects

  1. Scoliosis is an abnormal lateral S-like or C-like curvature of the spine. These present as uneven shoulders, a curve in the spine, and uneven hips.
    • When the patient bends forward, uneven shoulders also manifest in scoliosis.
    • Management:
      • Scoliosis braces (e.g. Orthotics, Milwaukee Brace) are often worn under clothing as one method to attempt to improve the exaggerated curvature of the spine as seen in scoliosis. These may be worn for up to 23 hours a day.
  2. Kyphosis: a “hunchback” or “slouching” posture induced by excessive curvature of the spine, causing a bowing of the back such that the apex of the angle points backwards.
  3. Lordosis: an excessive curvature in the lumbar portion of the spine, giving a “swayback” appearance.
    • This position may be normal for pregnant patients.

Surgical Instrumentation may utilize metal implants fixed to the spine to improve the spinal deformity as the fusion of the bones mature.

  • Bone grafts may be used to “fill-in” areas where fusion is required for correction of the deformities.

Fractures

A complete or incomplete disruption in the continuity of bone structure, defined according to its type and extent. Fractures occur when bones are subjected to stress greater than it can absorb, such as in blows, crushing, twisting, or extreme muscle contractions. Adjacent structures are also affected which may result in soft tissue edema, hemorrhaging into muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels.

  • Fractures may be complete i.e. the break spans the entire cross section of the bone, or incomplete.

Typing

  1. Avulsion Fracture: a bone fragment is pulled from its bone by a ligament or tendon, commonly as a result of severe strains or sprains. These are suspected in third degree strains or grade three sprains, requiring an x-ray of the affected area.
  2. Buckle/Torus Fracture: a fracture resulting from compression of a bone along its axis, which deforms a bone to form a “torus” on the site of breakage. View here.
  3. Comminuted Fracture: a shattered bone producing shards of bone separate from the main bone fragments.
  4. Compression Fracture: a bone shattering from compression, often seen in the vertebral column, usually in patients with osteoporosis.
  5. Depressed Fracture: a fracture where fragments are driven inward into the body, often found in facial and skull fractures.
  6. Epiphyseal Fracture: a fracture through the epiphysis.
  7. Greenstick Fracture: a fracture on one side of the bone as a result of bending.
  8. Impacted Fracture: fractures where the two bone fragments are pushed together.
  9. Oblique Fracture: fractures that occurs at an angle to the bone.
  10. Open/Compound Fracture: a fracture that breaches the skin or mucous membranes. A complex fracture involves the surrounding muscles, tendons, ligaments, or other soft tissues, but does not break the skin.
  11. Pathologic Fracture: a fracture resulting from pathologies of the bone e.g. osteoporosis, bone cysts, Paget’s disease, bony metastasis/tumor; this may occur without any trauma to the bone. Due to its nature, this is also known as a “spontaneous fracture”.
  12. Simple Fracture: a fracture that remains contained, without breaching skin integrity, also referred to as a “closed fracture”.
  13. Spiral Fracture: a fracture that twists around the shaft of the bone.
  14. Stress Fracture: a fracture resulting from repeated loading of a bone. Also known as a fatigue fracture.
  15. Transverse Fracture: a break that travels straight across a bone.

Clinical Manifestations

  1. Pain felt continuously and progressively until the bone fragments are immobilized. This increases with muscle spasming (splinting) that begin soon after the initial injury.
  2. Loss of Function: function of muscles related to bone integrity may be compromised due to damage to the bone. Pain also contributes to the loss of function. Abnormal movement (false motion) may also be involved.
  3. Deformity: displacement, angulation, or rotation of bone fragments. These may be immediately visible or palpable. Compare affected limbs with unaffected limbs.
  4. Shortening of the affected extremity from muscle splinting, either as bone fragments are pushed together or misalign and overlap.
  5. Crepitus, a scratching, rough feeling or sound felt when moving the affected area as the bone fragments rub against each other.
  6. Swelling (localized edema) and Discoloration (ecchymosis) occur as a result of bleeding into the tissues, and may not develop until several hours after the injury.

Management

  1. Emergent Management: when suspected, the affected area should be immediately immobilized before the patient is moved. Adequate splinting is essential.
    • Anatomical Splinting is a technique by which body is used as a splint for the affected region e.g. using the unaffected leg as a splint.

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